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","C","D","E"]

Explanation

Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determine its antibiotic susceptibility, guiding appropriate treatment.

C. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess for signs of infection and the body's immune response to the MRSA infection.

D. Use standard precautions and wear a mask.

Standard precautions should always be followed to prevent the transmission of infections in healthcare settings. Wearing a mask may be indicated if there is a risk of respiratory droplet transmission during wound care or other procedures.

E. Institute contact precautions for staff and visitors.

Contact precautions should be implemented to prevent the spread of MRSA to others. This includes wearing gloves and gowns when providing care, as well as educating staff and visitors about proper hand hygiene and infection control measures.

A. Underline key words on the written information. B. Speak loudly and face the client. C. Use everyday language when explaining issues. D. Provide a very well-lit meeting space.

Correct Answer is C

Explanation

C. When providing health teaching to older adult clients, using everyday language is crucial. Older adults may have varying levels of health literacy and cognitive abilities, so using simple, clear language facilitates better understanding and comprehension of the information being provided.

A. Underlining key words on the written information may be helpful for emphasizing important points, but it is not as critical as using everyday language to enhance understanding

B. Speaking loudly and facing the client may not be necessary for all older adult clients and could even be perceived as patronizing or disrespectful.

D. Providing a very well-lit meeting space is important for optimizing visual acuity, especially for older adults who may have age-related changes in vision. However, while adequate lighting is beneficial, it is not as critical

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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

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin- resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?