When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?
Modify the nursing interventions to achieve the client's goals.
Determine if the expected outcomes were realistic.
Obtain current client data to compare with expected outcomes.
Review related professional standards of care.
The Correct Answer is C
Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.
Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.
Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.
Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Potassium 3.5 mEq/L and sodium 142 mEq/L are within normal ranges, not expected after vomiting and diarrhea which typically cause hypokalemia and hypernatremia due to fluid loss.
Choice B rationale: Potassium 4.5 mEq/L and sodium 140 mEq/L remain normal, not consistent with dehydration and gastrointestinal fluid loss, which usually lower potassium and elevate sodium concentration.
Choice C rationale: Potassium 5.0 mEq/L and sodium 138 mEq/L are normal values, not typical after prolonged vomiting and diarrhea, where potassium decreases and sodium increases due to water deficit.
Choice D rationale: Potassium 3.0 mEq/L indicates hypokalemia from gastrointestinal losses, and sodium 149 mEq/L indicates hypernatremia from dehydration, both expected findings after vomiting and diarrhea.
Correct Answer is B
Explanation
Choice A reason: Starting with the most difficult questions can make the client uncomfortable and less likely to be open in the discussion.
Choice B reason: Beginning with less sensitive questions can help build rapport and make the client feel more comfortable discussing more intimate details later in the interview.
Choice C reason: Asking questions in a vague, non-specific format can lead to confusion and may not yield the necessary information.
Choice D reason: Sharing personal values is not appropriate as it can bias the interaction and may make the client feel judged or uncomfortable.
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