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 D
Explanation
Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.
Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.
Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.
Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.
Correct Answer is A
Explanation
Choice A reason: Home care is the most appropriate resource referral for this client, as they will need skilled nursing care to perform wound care and monitor the healing process. Home care can also provide education and support for the client and their family.
Choice B reason: Assisted living is not a suitable resource referral for this client, as they do not provide skilled nursing care or wound care. Assisted living facilities are designed for clients who need assistance with activities of daily living, but not medical care.
Choice C reason: Long-term care is not a necessary resource referral for this client, as they do not have a chronic or terminal condition that requires 24hour nursing care. Long-term care facilities are intended for clients who are unable to live independently due to physical or cognitive impairments.
Choice D reason: Hospice care is not an appropriate resource referral for this client, as they do not have a terminal illness or a life expectancy of less than six months. Hospice care provides palliative care and comfort measures for clients who are dying and their families.
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