A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?

Assessment

Evaluation

implementation

Planning

Answer and Explanation

The Correct Answer is D

A.   Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B.   Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C.   Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D.   Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.

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Correct Answer is D

Explanation

A. Educators typically disseminate knowledge to others, but they don't necessarily collect data to generate new knowledge.
B. Advocates primarily support and defend the rights or interests of others. While this can involve data collection, it's not the primary focus in this scenario.
C. Mentors provide guidance and support to individuals, but they are not typically involved in research or data collection.
D. Researchers systematically collect and analyze data to answer questions and contribute to knowledge. In this case, the nurse is conducting research to determine the best practices for reducing pressure injuries.

A. Client reports dull, aching pain in lower right calf. B. Client reports nausea following administration of pain medication. C. Client's oral temperature is 38.4° C (101.2° F). D. Client reports the rash on their back is itchy. E. Client has a vesicular rash on their upper back.

Correct Answer is ["A","B","D"]

Explanation

A. This is subjective data. The description of pain as "dull" and "aching" is based on the client's personal experience and cannot be measured directly by the nurse. Pain is a subjective symptom because it varies from person to person and is reported by the patient.
B. This is subjective data. Nausea is a feeling or sensation reported by the client and is based on their personal experience. The nurse relies on the client's report to assess this symptom, as it cannot be directly observed or measured.
C. This is objective data. The temperature reading is a measurable, quantifiable fact that can be directly observed and recorded by the nurse using a thermometer. It provides concrete evidence of the client's condition.
D. This is subjective data. Itchiness is a sensation reported by the client and is based on their personal experience. The nurse cannot measure itchiness directly; they rely on the client’s description to understand the symptom.
E. This is objective data. The presence of a vesicular rash is an observable finding that the nurse can see and document. It is a physical characteristic that can be directly assessed and recorded.

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A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data to determine the best practice for reducing pressure injuries in clients. Which of the following roles is the nurse taking?

Correct Answer is D

Explanation

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is teaching a class on professionalism. The nurse should include that which of the following is an example of responsibility?

A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the following legal torts applies to this situation?

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?

A nurse is teaching a class about professionalism. The nurse should include that leaving a computer terminal unattended after logging on is an example of which of the following?

A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

A nurse is caring for a client. Exhibits For which of the following interprofessional team members should the nurse anticipate a provider's referral? (Select all that apply).

A nurse is teaching a class on leadership. The nurse should include that which of the following are characteristics of situational leaders? (Select All that Apply.)