A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?

Assessment

Evaluation

implementation

Planning

Answer and Explanation

The Correct Answer is D

A.   Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B.   Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C.   Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D.   Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.

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Correct Answer is B

Explanation

A. A positive-pressure airflow room is designed to keep potentially contaminated air from entering the room, making it suitable for immunocompromised patients who need protection from airborne pathogens. However, for a client with symptoms suggestive of tuberculosis (TB), such as a productive cough and a positive Mantoux test, a positive-pressure room is not appropriate.
B. A negative-pressure airflow room is specifically designed to contain airborne pathogens within the room and prevent their spread to other areas. This is the appropriate type of room for a client with symptoms indicative of TB, as it helps to ensure that any infectious particles are not dispersed into the general environment.
C. A semi-private, positive-pressure airflow room is not suitable for a patient with a suspected infectious disease like TB. The positive pressure could potentially allow airborne pathogens to escape from the room, which poses a risk to others. This type of room is generally used for patients who need protection from external pathogens rather than those who may be spreading infection.
D. While a negative-pressure room is appropriate for controlling airborne pathogens, a semi-private room may not be suitable for a patient with a suspected infectious disease like TB. TB patients should ideally be placed in a private room to avoid potential exposure to other patients, as semi-private rooms could still allow for transmission of airborne diseases between patients.

A. The AP's rapport with clients B. The AP has the knowledge and skill to perform the task C. The AP's ability to complete the task without assistance D. The AP's ability to prioritize

Correct Answer is B

Explanation

A. While having a good rapport with clients is important for effective care, it is not one of the five rights of delegation. Rapport affects client interactions and overall satisfaction but does not directly impact the appropriateness of delegating a specific task.
B. This is a critical consideration under the "Right Person" component of the five rights of delegation. The nurse must ensure that the AP has the appropriate knowledge, skills, and competencies to perform the delegated task safely and effectively. This ensures that the task is performed correctly and reduces the risk of errors.
C. The ability of the AP to complete the task without assistance is related to the "Right Person" and "Right Task" components. However, it is not always necessary for the AP to complete the task independently, as some tasks may require supervision or periodic check-ins.
D. While the AP’s ability to prioritize tasks can be valuable, it is not one of the five rights of delegation. The nurse should provide clear instructions and prioritize tasks as part of effective delegation, but the specific ability of the AP to prioritize independently is not a primary factor in the delegation process.

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A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

Correct Answer is B

Explanation

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