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 D

Explanation

D. Severe obstructive sleep apnea poses a risk of respiratory compromise, particularly when compounded by the effects of opioid analgesics, which can depress respiratory drive. Applying the client's prescribed positive airway pressure (PAP) device, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), helps maintain airway patency and ensures adequate ventilation

A. It promotes better alignment of the airway, decreasing the likelihood of obstruction by the tongue or soft tissues. While this intervention is beneficial for managing OSA, it may not be the most critical intervention in this context.

B. Removing dentures or oral appliances may be necessary to prevent airway obstruction, especially during sleep when muscle tone is decreased. However, it is not the most critical intervention in this scenario

C. Securing side rails is important for client safety, especially in postoperative settings where clients may be at risk of falls. However, it does not directly address the client's obstructive sleep apnea or potential respiratory compromise from opioid administration.

Correct Answer is ["1"]

Explanation

There are 5 mL in one teaspoon, and 1 tablespoon is equivalent to 3 teaspoons, there are 15 mL in one tablespoon.

So, if 15 mL contains 30 mg of dextromethorphan, then:

1 tablespoon (15 mL) contains 30 mg of dextromethorphan.

Therefore, the nurse should instruct the client to take: 1 tablespoon

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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 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?

Correct Answer is D

Explanation

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.)

Correct Answer is ["1"]

Explanation

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