47. 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?

Review related professional standards of care.

Obtain current client data to compare with expected outcomes.

Determine if the expected outcomes were realistic.

Modify the nursing interventions to achieve the client's goals.

Answer and Explanation

The Correct Answer is B

A. Review related professional standards of care: While standards of care guide best practices, evaluating effectiveness of care focuses first on comparing actual client data with the expected outcomes, not professional benchmarks.

B. Obtain current client data to compare with expected outcomes: This is the next logical step after reviewing expected outcomes. Evaluating effectiveness requires assessing the client's current condition to determine if goals have been met.

C. Determine if the expected outcomes were realistic: Assessing the realism of goals is part of care planning and revision, but not the immediate next step when evaluating outcomes. It comes later if goals are not met.

D. Modify the nursing interventions to achieve the client's goals: Interventions are modified only after determining whether the original interventions were effective, which requires reviewing client progress and comparing it to the expected outcomes.

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Correct Answer is A

Explanation

A. Release and reinsert the flowmeter in the wall outlet: A loud hissing sound suggests the flowmeter is not securely connected to the oxygen outlet, potentially causing gas leakage. Reinserting the flowmeter ensures a proper seal and safe delivery of oxygen.

B. Attach the flowmeter to a humidification canister: Humidification may be appropriate depending on oxygen flow rate and duration, but it does not address the immediate issue of a possible loose or faulty connection causing the hissing sound.

C. Adjust the flow rate to the prescribed liters per minute: Adjusting the flow rate should only occur once the equipment is properly connected and no leaks are present. Doing so beforehand may worsen gas leakage or result in inaccurate delivery.

D. Assess the position of the mask on the client’s face: While mask placement is important for oxygen delivery, the hissing sound is unrelated to the mask fit and indicates a problem at the wall outlet connection.

A. An antibiotic, to be administered every 6 hours starting at 0900. B. A diuretic, to be administered every 12 hours, at 0900 and 2100. C. An antianxiety agent, to be administered every day at 0900. D. An analgesic topical patch, to be replaced every 24 hours at 0900

Correct Answer is A

Explanation

A. An antibiotic, to be administered every 6 hours starting at 0900: Timely administration of antibiotics is critical to maintain therapeutic blood levels and combat infection effectively. Delays can reduce efficacy and contribute to resistance, making it the priority.

B. A diuretic, to be administered every 12 hours, at 0900 and 2100: While timing is important for diuretics to manage fluid balance, they are less time-sensitive than the initial dose of an antibiotic.

C. An antianxiety agent, to be administered every day at 0900: Antianxiety medications provide symptom relief, but delayed administration typically does not cause immediate harm compared to time-sensitive medications like antibiotics.

D. An analgesic topical patch, to be replaced every 24 hours at 0900: Pain control is important, but a brief delay in patch replacement is unlikely to result in abrupt symptom worsening. It is not as critical as initiating an antibiotic regimen on schedule.

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47. 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

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Correct Answer is A

Explanation

When administering 0900 medications to four clients, which prescription should the nurse administer first?

Correct Answer is A

Explanation

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