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 A

Explanation

Choice A reason: An increased boundary of the wound suggests possible infection or inflammation. C-reactive protein (CRP) is an acute-phase reactant produced by the liver in response to inflammation. A CRP test can help assess the severity of inflammation or infection. The normal range for CRP is generally below 10 mg/L.

Choice B reason: While serum potassium and sodium levels are important electrolytes to monitor, they are not directly related to wound assessment or infection. Normal ranges for potassium are 3.6 to 5.2 mmol/L, and for sodium, 135 to 145 mEq/L.

Choice C reason: Neutrophils are white blood cells that respond to infection. While an elevated neutrophil count can indicate infection, it is not as specific as CRP for inflammation. The normal range for neutrophils is 2,500 to 6,000 cells/mcL.

Choice D reason: Platelets are involved in clotting and would not necessarily change due to wound infection or inflammation. The normal platelet count range is 150,000 to 450,000 platelets/mcL.

A. Offer comfort that healing can happen at any point in time. B. Offer strategies the spouse can use to provide comfort to the client. C. Suggest that the spouse go home for a while and get some sleep. D. Explain that the staff will strive to keep the client comfortable.

Correct Answer is D

Explanation

Choice A reason: Offering comfort that healing can happen at any point in time may not be appropriate for a client in the terminal stage of lung cancer, as it may give false hope.

Choice B reason: Offering strategies to provide comfort to the client can be helpful, but it does not address the spouse's immediate emotional needs.

Choice C reason: Suggesting that the spouse go home to sleep may seem dismissive of the spouse's current emotional state and need for support.

Choice D reason: Explaining that the staff will strive to keep the client comfortable addresses the spouse's concern for the client's well-being and provides reassurance about the care being provided.

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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?

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Naxlex Comprehensive Predictor Exams

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer is A

Explanation

A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

Correct Answer is D

Explanation

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