When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Compare the client's manifestations with the defining criteria of related problems.

Review the priority nursing problems included in the plan of care.

List the nursing actions that need to be implemented most immediately.

Ensure that all treatments prescribed by the healthcare provider have been initiated.

Answer and Explanation

The Correct Answer is B

A. When identifying goals to be included in a client's plan of care, the nurse should compare the client's manifestations (signs and symptoms) with the defining criteria of related nursing problems or diagnoses. This involves assessing the client's current health status, identifying specific problems or areas of concern, and determining desired outcomes or goals for improvement.

B. Reviewing the priority nursing problems already included in the plan of care helps the nurse understand the client's current status and ongoing care needs. However, this may leave out other client needs not stated as priority

C. While listing immediate nursing actions is important for addressing urgent care needs, it does not directly address the process of identifying goals for the client's plan of care.

D. Ensuring that prescribed treatments have been initiated is an important aspect of client care, but it pertains more to implementation rather than goal identification.

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Correct Answer is B

Explanation

B. When applying restraints, ensuring that they can be quickly released is essential for maintaining the safety and well-being of the client. This is especially important in cases where restraints are used to prevent harm or injury to the client, as they should only be used as a last resort and for the shortest duration necessary.

A. Checking capillary refill provides valuable information about peripheral perfusion and the adequacy of blood flow to the extremities. However, ensuring the restraints can be released easily is more crucial.

C. While replacing the nasogastric tube may be necessary if it has been removed, it's not the most immediate concern after applying wrist restraints. The priority is to ensure the safety and comfort of the patient with the restraints in place.

D. Reinserting the peripheral IV catheter may be necessary if it has been dislodged. However, it's not the most critical action immediately after applying wrist restraints.

A. Uses an oral airway to keep the teeth apart. B. Places the client in a supine position. C. Tests for a gag reflex before performing oral care. D. Suctions secretions from the posterior pharynx.

Correct Answer is B

Explanation

A. Using an oral airway can be appropriate in some situations to keep the mouth open and facilitate oral care, especially in an unconscious client. This helps prevent biting and allows for easier access to the oral cavity. Therefore, this action does not indicate a need for additional training.

B. Placing an unconscious client in a supine position for oral care can be inappropriate, as it increases the risk of aspiration, especially if there are secretions in the mouth. It is generally safer to position the client in a lateral position to minimize this risk. This action may indicate a need for additional training.

C. Testing for a gag reflex before performing oral care is a standard precaution, especially for unconscious clients. This helps prevent aspiration and ensures the safety of the client during the procedure.

D. Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration, especially for unconscious clients who may have difficulty managing their secretions.

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When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly removed the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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