A nurse is changing a wound dressing for a post-op client. Which of the following steps is the nurse performing?

Choice A rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data and identified nursing diagnoses. It involves setting goals and determining the appropriate interventions to achieve those goals. In this scenario, the nurse is not developing a plan but rather observing the effects of an intervention that has already been implemented.
Choice B rationale
Assessment is the initial phase of the nursing process where the nurse collects and analyzes data about the client’s health status. This includes gathering information through observation, interviews, physical examinations, and diagnostic tests. In this scenario, the nurse is not collecting new data but rather observing the outcome of a previously administered medication.
Choice C rationale
Evaluation is the phase of the nursing process where the nurse assesses the client’s response to the interventions and determines whether the goals of care have been met. In this scenario, the nurse is evaluating the effectiveness of the antihypertensive medication by noting the decrease in the client’s blood pressure. This assessment helps determine if the medication is achieving the desired therapeutic effect.
Choice D rationale
Analysis is the phase of the nursing process where the nurse interprets the assessment data to identify the client’s health problems and needs. It involves critical thinking and clinical judgment to determine the underlying causes of the client’s condition. In this scenario, the nurse is not analyzing data but rather evaluating the outcome of an intervention.

Choice A rationale
Providing an opportunity for team members to ask questions is important for effective communication and teamwork, but it is not the primary action to verify the correct patient, procedure, and surgery. This action is more related to ensuring that all team members are on the same page and can clarify any doubts, but it does not directly verify the patient’s identity and procedure.
Choice B rationale
Discussing personal matters unrelated to the surgery is incorrect and unprofessional. It does not contribute to verifying the correct patient, procedure, and surgery. This action can lead to distractions and potential errors in patient care.
Choice C rationale
Reviewing the surgical instruments and equipment is important for ensuring that the necessary tools are available and functioning properly, but it does not directly verify the patient’s identity and procedure. This action is more related to the preparation and readiness of the surgical team.
Choice D rationale
Confirming the patient’s identity and procedure is the correct action to verify the correct patient, procedure, and surgery. This involves verifying the patient’s identity using at least two identifiers, confirming the procedure with the patient or their representative, and ensuring that the correct procedure is on the schedule. This step is crucial to prevent wrong-site, wrong- procedure, and wrong-patient surgeries.