When a female client preparing for surgery suddenly bursts into tears, the nurse should take which of the following actions? · Select one answer

Choice A reason: This is incorrect because placing soiled linens in the dirty linen receptacle can expose other clients and staff to the hepatitis virus, which can be transmited through blood and body fluids.

Choice B reason: This is incorrect because placing soiled linens on the floor can create a safety hazard and a potential source of infection for anyone who comes in contact with them.

Choice C reason: This is correct because placing soiled linens in a plastic bag that has the contamination symbol can prevent the spread of infection and alert the laundry department to handle them with caution.

Choice D reason: This is incorrect because placing soiled linens in the hazardous waste receptacle can waste resources and violate the regulations for disposing of hazardous materials.

Choice A reason: Implementation is a phase of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. The nurse’s actions do not reflect this phase, as they are not performing any interventions or activities, but rather observing and measuring the client’s condition. Therefore, this choice is incorrect.

Choice B reason: Evaluation is a phase of the nursing process that involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. It also involves comparing the actual outcomes with the expected outcomes, and modifying the plan of care if needed. The nurse’s actions reflect this phase, as they are assessing the client’s leg for signs of improvement or resolution of thrombophlebitis, and noting that the client is ready for discharge. Therefore, this choice is correct.

Choice C reason: Outcomes identification is a phase of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. The nurse’s actions do not reflect this phase, as they are not setting any goals, but rather evaluating whether they have been met.

Therefore, this choice is incorrect.

Choice D reason: Assessment is a phase of the nursing process that involves collecting and analyzing data about the client’s health status, history, and environment. It also involves identifying any factors that may affect the client’s health or well-being, and forming a nursing diagnosis. The nurse’s actions do not reflect this phase, as they are not collecting or analyzing any new data, but rather reviewing the existing data and confirming the diagnosis. Therefore, this choice is incorrect.