A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?
Planning
Evaluation
Data collection
Implementation
The Correct Answer is A
Choice A reason: This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
Choice B reason: This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
Choice C reason: This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
Choice D reason: This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Explaining the steps of a surgical procedure to a client is not unprofessional, but a professional duty of a nurse. A nurse should provide accurate and relevant information to the client about their health condition, treatment options, and expected outcomes, in order to help them make informed decisions and prepare for the procedure¹.
Choice B reason: This is incorrect. Witnessing a client consent for a surgical procedure is not unprofessional, but a professional responsibility of a nurse. A nurse should act as a witness to the client's signature on the consent form, and ensure that the consent process was conducted properly, ethically, and legally².
Choice C reason: This is the correct answer. Confirming that a client appears competent to consent to a surgical procedure is unprofessional, as it is not within the scope of practice of a nurse. A nurse cannot assess or determine the client's mental capacity or competence to consent, as this requires a medical evaluation by a physician or a psychologist³. A nurse can only observe and report the client's behavior, mood, and cognition to the health care team.
Choice D reason: This is incorrect. Verifying that a client voluntarily gave consent to a surgical procedure is not unprofessional, but a professional obligation of a nurse. A nurse should ensure that the client's consent was given freely, without any coercion, manipulation, or undue influence from others². A nurse should also respect the client's right to withdraw or change their consent at any time².
Correct Answer is A
Explanation
Choice A reason: Telephone number is an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, telephone number is one of the approved patient identifiers that can be used to reliably identify the individual as the person for whom the service or treatment is intended. Telephone number is a person specific identifier that is unlikely to be shared by another client.
Choice B reason: Room number is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, room number is not an example of a unique patient identifier. Room number is not a person specific identifier, but a location specific identifier that can change or be assigned to another client.
Choice C reason: Medical condition is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, medical condition is not an example of a unique patient identifier. Medical condition is not a person specific identifier, but a health specific identifier that can be common or vague among different clients.
Choice D reason: Home address is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, home address is not an example of a unique patient identifier. Home address is not a person specific identifier, but a place specific identifier that can be shared or changed by the client.
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