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Planning and outcome identification > Fundamentals
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Practice Exercise 3
Total Questions : 6
Showing 6 questions, Sign in for moreThe nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client’s pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan?
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated goal/ outcome? The client will
A nurse is planning care for a newly admitted client. Place the following activities of planning in the correct order of their use.
Explanation
The planning phase of the nursing process is a systematic, multi-step clinical methodology designed to design nursing actions that resolve client-specific problems. Each phase of this planning sequence relies on the logical completion of the preceding step, ensuring that clinical interventions directly target prioritized client needs and are documented accurately.
Rationale for correct answer:
The correct sequence begins with setting priorities (3) to determine which nursing diagnoses require immediate attention based on safety frameworks. Next, the nurse must establish goals and outcomes (1) to define what the client should achieve. Once outcomes are set, the nurse chooses interventions (4) designed to meet those goals, and finally writes the care plan (2) to document and communicate the complete strategy.
Test-taking strategy
- Analyze the scenario and question: The nurse is planning care for a newly admitted client. The question requires placing the four core activities of the planning phase of the nursing process in the correct chronological order of clinical execution.
- Apply logical clinical workflow: Use a structured step-by-step methodology to determine the correct order of operations.
- Step 1: The nurse must first decide what to address first. This is prioritization, meaning 3 is the first step.
- Step 2: Once priorities are clear, the nurse must establish the target goals/outcomes. This puts 1 as the second step.
- Step 3: To meet those established goals, the nurse selects specific nursing actions. This places 4 as the third step.
- Step 4: Finally, the nurse compiles and documents all these elements. This places 2 as the final step, establishing the sequence 3, 1, 4, B.
Take home points
- Prioritizing nursing diagnoses must occur before any other planning activity to ensure life-threatening issues are addressed first.
- Patient-centered goals and outcomes must be established before selecting interventions to ensure all actions are goal-directed.
- Choosing specific nursing interventions is the third step, mapping clinical actions directly to the desired client outcomes.
- Writing and documenting the care plan is the final step of the planning phase, ensuring the plan can be communicated and executed.
A nurse is completing the outcome identification and planning step of the nursing process. The nurse works in partnership with the client and family to do which of the following? Select all that apply
A nurse is prioritizing client problems using Maslow’s hierarchy of human needs. For the following nursing diagnoses:
- Disturbed Body Image
- Ineffective Airway Clearance
- Spiritual Distress
- Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow’s hierarchy of human needs?
A nurse is reviewing several written outcomes for clients. Which of the following outcomes are correctly written? Select all that apply
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