A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Establishing the priorities of client care

Reinforcing teaching about the client's diagnosis

Asking the client about the presence of pain

Comparing the client's current laboratory values to previous results

Answer and Explanation

The Correct Answer is B

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

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Correct Answer is A

Explanation

A) ADL (Activities of Daily Living): This abbreviation is commonly used in healthcare documentation to refer to the routine tasks individuals perform independently for self-care, such as bathing, dressing, grooming, and toileting. Reminding the newly licensed nurse to use the abbreviation ADL ensures clear and concise documentation of the client's functional status and care needs.

B) SQ: While SQ could stand for subcutaneous (as in SQ injection), it's generally recommended to use the full term "subcutaneous" in documentation to avoid confusion or misinterpretation. Using abbreviations like SQ can lead to errors or miscommunication in healthcare settings.

C) AU: This abbreviation typically stands for "each ear" when documenting information related to the ears, such as when administering eardrops or assessing for symptoms. However, similar to SQ, it's preferable to use the full term "each ear" in documentation to ensure clarity and avoid ambiguity.

D) HS: HS commonly stands for "hour of sleep" or "at bedtime" when documenting medication administration times. However, like other abbreviations, it's advisable to use the full term "at bedtime" to prevent misunderstandings or errors related to medication dosing schedules.

A. Asking a staff member from another unit to complete the evaluation B. Focusing primarily on areas that need improvement C. Discussing the evaluation with the nurse manager D. Linking the evaluation to predetermined standards

Correct Answer is D

Explanation

A) Asking a staff member from another unit to complete the evaluation: While involving someone from another unit may offer an external perspective, it may not necessarily ensure impartiality. The evaluator should have direct knowledge of the nurse's performance to provide a fair assessment.

B) Focusing primarily on areas that need improvement: This approach may lead to a biased evaluation, as it overlooks the nurse's strengths and positive contributions. A comprehensive evaluation should consider both areas of strength and areas needing improvement to provide a balanced assessment.

C) Discussing the evaluation with the nurse manager: Consulting with the nurse manager about the evaluation could introduce bias, especially if the manager has preconceived notions about the nurse being evaluated. Peer evaluations should aim to be independent of managerial influence to maintain impartiality.

D) Linking the evaluation to predetermined standards: This is the correct approach to ensure impartiality in peer evaluation. By using predetermined standards or criteria, the evaluation process becomes objective and transparent. Evaluators can assess the nurse's performance against established benchmarks, reducing the influence of personal bias.

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A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

Correct Answer is A

Explanation

A nurse is completing a peer evaluation. Which of the following actions will ensure the peer evaluation is impartial?

Correct Answer is D

Explanation

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