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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: While teaching alternative ways to manage pain is important, it does not address the immediate issue of the client not taking the medication as prescribed.

Choice B reason: The client should be instructed to take the medication as prescribed to maintain consistent pain control and prevent breakthrough pain.

Choice C reason: Advising the client to take the medication only with severe pain is contrary to the prescribed regimen and could lead to inadequate pain management.

Choice D reason: It is important to discuss the risks of long-term medication use, but the priority is to ensure that the client understands the importance of taking the medication as prescribed for effective pain management.

A. Hand washing only needs to be performed when exiting the client’s room. B. This client requires contact and droplet precautions. C. A gown and gloves should be worn any time there is potential for contact with secretions. D. A mask should always be worn when in the client’s room. E. This client would require a private room if admitted.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.

Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.

Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.

Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.

Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?

Correct Answer is B

Explanation

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

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