A nurse is recognizing errors or omissions in a plan of care for a client with chronic kidney disease who is on hemodialysis. Which of the following actions should the nurse take?

Report the errors or omissions to the quality improvement committee.

Discuss the errors or omissions with the health care team and revise the plan of care accordingly.

Ignore the errors or omissions as they are not significant enough to affect outcomes.

Document the errors or omissions in an incident report and file it in the client's chart.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Reporting the errors or omissions to the quality improvement committee is not the best action to take because it does not address the immediate needs of the client or correct the plan of care. Quality improvement committees are responsible for monitoring and evaluating the quality of care and services provided by the health care organization, but they are not directly involved in the care of individual clients. Reporting the errors or omissions to the committee may be appropriate after discussing and revising the plan of care with the health care team, but it is not the first or most important action to take.

Choice B reason:

Discussing the errors or omissions with the health care team and revising the plan of care accordingly is the best action to take because it ensures that the client receives safe and effective care that meets their needs and preferences. Errors or omissions in a plan of care are failures to do the right thing that may cause harm or poor outcomes for the client Examples of errors or omissions in a plan of care include failing to order necessary tests, procedures, medications, or consultations; failing to document or communicate important information; failing to monitor or evaluate the client's condition or response to treatment; or failing to follow evidence-based guidelines or standards of care Discussing the errors or omissions with the health care team allows for identifying and correcting the causes of the errors or omissions, such as lack of knowledge, skills, resources, communication, coordination, or supervision. Revising the plan of care accordingly allows for updating and modifying the goals, interventions, and outcomes based on the client's current status and needs.

Choice C reason:

Ignoring the errors or omissions as they are not significant enough to affect outcomes is not a good action to take because it violates the ethical principles of beneficence and nonmaleficence, which require nurses to do good and avoid harm for their clients Ignoring the errors or omissions may also lead to legal consequences, such as negligence or malpractice claims, if the client suffers harm or injury as a result of the errors or omissions Furthermore, ignoring the errors or omissions does not contribute to improving the quality and safety of care or preventing future errors or omissions from occurring.

Choice D reason:

Documenting the errors or omissions in an incident report and filing it in the client's chart is not a good action to take because it does not correct the errors or omissions or revise the plan of care. Incident reports are tools for documenting and analyzing adverse events or near misses that occur in health care settings, such as medication errors, falls, infections, or equipment failures Incident reports are not part of the client's medical record and should not be filed in their chart. They are confidential documents that are used for quality improvement purposes, such as identifying system failures, implementing corrective actions,.

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Correct Answer is A

Explanation

Choice A reason:

Assessing the patient's vital signs and oxygen saturation is the first step in evaluating the patient's response to pain medication. This is because vital signs and oxygen saturation can indicate the severity of pain, the effectiveness of the medication, and the presence of any adverse effects such as respiratory depression or hypotension. Assessing vital signs and oxygen saturation is also consistent with the nursing process of assessment, which guides the nurse's subsequent actions.

Choice B reason:

Notifying the physician and requesting a different medication is not the first action that the nurse should take. The nurse should first assess the patient's condition and determine the cause of inadequate pain relief. The physician may not be available or may not agree to change the medication without further information. Changing the medication may also not be necessary or appropriate, depending on the patient's pain level, type of pain, allergies, contraindications, and preferences.

Choice C reason:

Reassessing the patient's pain level in another 15 minutes is not the first action that the nurse should take. The patient is reporting a high level of pain (8 out of 10) despite receiving morphine 10 mg intravenously 30 minutes ago. This indicates that the patient is experiencing breakthrough pain, which is a sudden increase in pain intensity that occurs despite adequate analgesia. Breakthrough pain requires immediate attention and intervention, not delayed reassessment.

Choice D reason:

Providing nonpharmacological interventions such as massage or distraction is not the first action that the nurse should take. Nonpharmacological interventions are complementary methods that can enhance the effect of pharmacological interventions, but they are not sufficient to treat severe acute pain by themselves. The nurse should first assess the patient's condition and administer additional analgesia if indicated and prescribed before implementing nonpharmacological interventions.

A. Establish a baseline for planning care and evaluating outcomes. B. Identify the client's response to health concerns or illness. C. Provide goal-directed, client-centered care. D. Compare the client's data with expected standards or reference ranges.

Correct Answer is A

Explanation

Choice A reason:.

Establishing a baseline for planning care and evaluating outcomes is the main purpose of the assessment phase of the nursing process. The assessment phase involves collecting data about the client's health status and needs, which will help the nurse to identify any problems or potential problems that may need to be addressed. The assessment data will also serve as a reference point for comparing the client's progress and outcomes throughout the nursing process.

Choice B reason:.

Identifying the client's response to health concerns or illness is part of the diagnosis phase of the nursing process. The diagnosis phase involves analyzing the data collected during the assessment phase and identifying the client's problems and strengths. The nurse then formulates a nursing diagnosis, which is a statement of the client's actual or potential health problem that can be addressed by nursing interventions.

Choice C reason:.

Providing goal-directed, client-centered care is part of the planning and implementation phases of the nursing process. The planning phase involves setting goals and outcomes for the client and selecting appropriate interventions to achieve them. The goals and outcomes should be specific, measurable, attainable, realistic, and timely (SMART), and they should reflect the client's preferences and values. The implementation phase involves carrying out the interventions and documenting the actions and responses. The interventions should be evidence-based, safe, and effective, and they should involve the client as much as possible.

Choice D reason:.

Comparing the client's data with expected standards or reference ranges is part of the evaluation phase of the nursing process. The evaluation phase involves evaluating the effectiveness of the interventions and modifying the plan as needed. The nurse compares the client's actual outcomes with the expected outcomes and determines whether the goals have been met, partially met, or not met. The nurse also identifies any factors that may have influenced the outcomes, such as client compliance, environmental factors, or unexpected events.

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A nurse is recognizing errors or omissions in a plan of care for a client with chronic kidney disease who is on hemodialysis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a patient's response to pain medication after surgery. The patient reports that his pain level is 8 out of 10 on a numeric rating scale, despite receiving morphine 10 mg intravenously 30 minutes ago. What should the nurse do first?

Correct Answer is A

Explanation

A nurse is conducting an initial assessment for a client who was admitted with pneumonia. Which of the following actions should the nurse take during this phase of the nursing process?

Correct Answer is A

Explanation

A nurse is conducting an assessment on a client who has multiple sclerosis (MS). Which of the following data should the nurse collect? (Select all that apply.).

A nurse is recognizing errors or omissions in a plan of care for a client with chronic kidney disease who is on hemodialysis. Which of the following actions should the nurse take?

A nurse is reviewing the steps of the nursing process with a group of nursing students. Which of the following statements by one of the students indicates an understanding of the evaluation phase?

A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?

A nurse is identifying factors that contribute to success or failure of a plan of care for a client with anxiety disorder who is undergoing cognitive behavioral therapy (CBT). Which of the following factors should the nurse consider? (Select all that apply.).

A nurse is using appropriate resources and equipment when implementing care for a client who has impaired mobility due to a stroke. Which of the following actions by the nurse demonstrates this skill?

A nurse is developing a plan of care for a client who has diabetes mellitus. Which of the following actions should the nurse take first?

Which of these is an example of a goal rather than an outcome?