A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?
Data collection
Evaluation
Planning
Implementation
The Correct Answer is C
Explanation:
A. Data collection:
Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, psychological, social, and environmental factors. This involves conducting assessments, obtaining medical histories, performing physical exams, reviewing diagnostic tests, and gathering information from the client, family members, and other healthcare providers. In the scenario, data collection would involve gathering information about the client's postoperative condition, recovery progress, functional abilities, support system, home environment, and any other relevant factors that would influence the discharge planning process.
B. Evaluation:
Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions, measures progress toward goals, and determines the effectiveness of the care provided. It involves comparing the client's actual outcomes with expected outcomes, identifying any deviations or areas needing improvement, and making adjustments to the care plan as necessary. In the scenario, evaluation would occur after the implementation of the discharge plan to assess the client's readiness for discharge, the achievement of goals, and the overall success of the interventions implemented.
C. Planning:
Planning is the phase of the nursing process where the nurse, in collaboration with the client, family, and healthcare team members, develops a comprehensive plan of care based on the collected data and identified needs. This includes setting priorities, establishing expected outcomes and goals, determining appropriate interventions, creating a timeline for implementation, and coordinating resources and services. In the scenario, planning involves working with the social worker and physical therapist to develop a discharge plan that addresses the client's postoperative needs, ensures continuity of care, promotes recovery, and supports a smooth transition from the healthcare facility to the home or next level of care.
D. Implementation:
Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the care plan. This involves putting the plan into action, providing direct care, educating the client and family, coordinating services, monitoring progress, and advocating for the client's needs. In the scenario, implementation would occur as the nurse, along with the social worker and physical therapist, initiates the discharge plan, arranges for services and resources, provides education and instructions to the client and family, and ensures that all necessary preparations are made for the client's transition from the hospital.
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Related Questions
Correct Answer is B
Explanation
Explanation:
A. Arrange referral for family therapy to deal with home stressors:
While family therapy may be beneficial for addressing home stressors, it is not the first step when there is a suspicion of physical abuse. The priority in cases of suspected abuse is to ensure the client's safety and to report the suspicion to the appropriate authorities.
B. Follow the agency's guidelines for reporting suspected abuse:
This is the correct action to take first. Nurses are mandated reporters, and they must follow their agency's protocols and legal requirements for reporting suspected abuse. Reporting ensures that the client's situation is investigated promptly, and appropriate interventions are implemented to protect the client.
C. Check the bruises at the next visit to the client's home:
Delaying action and waiting until the next visit to check the bruises is not appropriate in cases of suspected abuse. Immediate action is necessary to address the safety of the client. Suspected abuse should be reported promptly to the relevant authorities for investigation.
D. Institute more frequent visits to the client's home:
Increasing the frequency of visits may not address the immediate safety concerns of the client if abuse is suspected. While increased monitoring may be necessary in certain situations, reporting the suspicion of abuse and initiating appropriate interventions should take precedence.
Correct Answer is D
Explanation
Explanation:
A. Place the head of the client's bed flat:
This action is not appropriate because lying flat can worsen dyspnea in many cases. It can restrict lung expansion and make breathing more difficult. Instead, the nurse should elevate the head of the bed or position the client in a semi-Fowler's or high-Fowler's position to facilitate easier breathing.
B. Perform nasotracheal suctioning for the client:
Nasotracheal suctioning is not indicated for dyspnea unless there is a specific medical reason, such as airway obstruction or excessive secretions. Performing suctioning without a clear indication can cause discomfort and may not address the underlying cause of dyspnea.
C. Increase the heat in the client's room:
Adjusting the room temperature is generally not a direct intervention for dyspnea. While maintaining a comfortable environment is important, dyspnea is usually managed through other means such as medication and positioning.
D. Administer an opioid narcotic to the client:
This is the most appropriate action among the choices provided. Opioid narcotics, such as morphine, are commonly used to alleviate dyspnea in end-of-life care. They help reduce the sensation of breathlessness, calm respiratory distress, and improve overall comfort for the client.
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