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 D

Explanation

A. "The healthcare provider will share this information with you.": This delays addressing the confidentiality and interpreter concerns. It does not clarify the nurse's responsibility regarding client privacy and use of proper translation services.

B. “I can give you those results as soon as I get them back from the lab.": Sharing medical information with a family member without proper client consent and without a qualified interpreter violates privacy and may result in miscommunication.

C. "I'm sorry, but your sibling's medical information is none of your business.": This response is overly harsh and unprofessional. While it reflects the need to maintain confidentiality, it lacks empathy and does not explain the proper protocol.

D. "I can only give medical information to the client with an approved interpreter.": This response maintains client confidentiality and ensures that communication is accurate and professional by using a trained interpreter. It respects both legal and ethical standards.

A. Facilitate a meeting between the HCP and the spouse. B. Document HCPs refusal to honor client's wishes. C. Have resuscitation equipment readily available. D. Notify the hospital ethical committee to assist with client's wishes.

Correct Answer is D

Explanation

A. Facilitate a meeting between the HCP and the spouse: While communication is important, the issue involves an ethical and legal conflict that requires broader institutional support beyond a one-on-one discussion.

B. Document HCP’s refusal to honor client’s wishes: Documentation is essential, but it is not a sufficient intervention to resolve the conflict or advocate for the client’s legal rights.

C. Have resuscitation equipment readily available: Taking this step contradicts the client’s expressed wishes in the living will and does not reflect advocacy for patient autonomy.

D. Notify the hospital ethical committee to assist with client’s wishes: This is the most appropriate action. The ethics committee can mediate the conflict between the healthcare provider and the client’s legal advance directive, ensuring the client’s rights and preferences are honored.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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