A nurse assesses the client and determines the client is at risk for infection. Which activity best reflects the planning phase of the nursing process?

The nurse formulates a goal "The client will be from infection for the duration of the hospitalization."

The nurse assesses the client’s white blood cell count

The nurse administers the ordered oral antibiotics

The nurse teaches the client the appropriate hand washing technique

Answer and Explanation

The Correct Answer is A

A) The nurse formulates a goal "The client will be free from infection for the duration of the hospitalization": This action reflects the planning phase of the nursing process. The planning phase involves setting goals and determining the best interventions to achieve the desired outcomes for the client. In this case, the goal is to prevent infection, which is a specific, measurable outcome that can guide further interventions.

B) The nurse assesses the client's white blood cell count: Assessing the client's white blood cell count is an important step in data collection, which is part of the assessment phase of the nursing process. It helps the nurse gather information about the client's current health status but is not a planning activity. The nurse would use the information from the assessment phase to formulate goals and plan interventions.

C) The nurse administers the ordered oral antibiotics: Administering antibiotics is an action related to the implementation phase of the nursing process. The implementation phase involves carrying out the planned interventions. In this case, the administration of antibiotics is a direct action taken to address the risk for infection, but it is not the planning phase.

D) The nurse teaches the client the appropriate hand washing technique: Teaching hand hygiene is an important intervention, but it falls under the implementation phase of the nursing process. It involves educating the client to help prevent infection, which is an action taken based on the goals and plan developed earlier. While important, it’s not the planning phase itself.

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Correct Answer is B

Explanation

A) "If you do not take it now, it will put you behind schedule.": While the nurse might be concerned about the medication schedule, this response dismisses the client's concern and doesn’t prioritize safety. The nurse should not pressure the client to take the medication before verifying that it is correct.
B) "Let me check the original order before you take it.": This is the best response because it demonstrates a commitment to patient safety. If the client is concerned about the medication, the nurse should take the time to verify the order directly from the original source to ensure the right medication is being given. This approach reassures the client and promotes trust.

C) "It wouldn't be listed here if it were not ordered for you!": This response can come across as dismissive and unprofessional. While it is important that the medication appears on the record, the nurse should still verify it to address the client's concern. Simply relying on the medication record without confirmation is not the best course of action.

D) "It's listed here on the medication sheet, so you should take it.": Similar to option C, this response dismisses the client’s concern and does not prioritize verifying the medication’s accuracy. It could lead to the client feeling their concerns were not taken seriously, which could negatively impact their trust in the care provided.

A. Problems that cause severe discomfort to the client B. Problems the client deems most important C. Problems that are immediately life-threatening for the client D. Problems that are identified as priority by the physician

Correct Answer is C

Explanation

A) Problems that cause severe discomfort to the client: While addressing discomfort is important in providing holistic care, it is not the highest priority in nursing. The nurse’s primary focus should be on life-threatening issues or those that could deteriorate the client’s condition rapidly. Severe discomfort can be managed once immediate threats to life are addressed.

B) Problems the client deems most important: Although it’s essential to consider the client’s perspective and involve them in their care plan, problems that are most important to the client may not always be the most urgent or life-threatening. For example, the client may prioritize pain management, but addressing life-threatening issues must always take precedence.

C) Problems that are immediately life-threatening for the client: This is the correct answer. According to Maslow’s hierarchy of needs and the nursing prioritization framework, life-threatening problems should always be the nurse's first priority. These are issues that, if not addressed immediately, can lead to death or severe complications. For instance, airway obstruction, severe bleeding, or shock would require immediate intervention.

D) Problems that are identified as priority by the physician: While the physician’s orders and priorities should be taken into consideration, the nurse must independently assess and prioritize care based on the overall health status of the client. This includes using clinical judgment to identify life-threatening conditions, even if they are not explicitly stated in the physician’s orders. Nurses are trained to identify priority issues through their assessments and are responsible for making decisions that ensure the client’s safety.

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A nurse assesses the client and determines the client is at risk for infection. Which activity best reflects the planning phase of the nursing process?

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