A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Compare data with normal values and standards.

Organize data into clusters that have similar underlying causes.

Validate data by using multiple sources of information.

Document data using standardized terminology and abbreviations.

Prioritize data according to urgency and importance.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

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Correct Answer is B

Explanation

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,.

A. "It involves determining the effectiveness of nursing interventions.”. B. "It involves establishing priorities and measurable outcomes.”. C. "It involves identifying gaps between actual and expected findings.”. D. "It involves selecting appropriate evidence-based interventions.".

Correct Answer is A

Explanation

Choice A reason:

It involves determining the effectiveness of nursing interventions. This is the correct definition of the evaluation phase of the nursing process, which is the final step where the nurse compares the actual outcomes with the expected outcomes and modifies the plan of care if needed.

Choice B reason:

It involves establishing priorities and measurable outcomes. This is not the correct definition of the evaluation phase, but rather the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

Choice C reason:

It involves identifying gaps between actual and expected findings. This is not the correct definition of the evaluation phase, but rather a component of it. Identifying gaps between actual and expected findings is one way to determine the effectiveness of nursing interventions, but it is not the only way. The evaluation phase also involves documenting and communicating the results of the evaluation.

Choice D reason:

It involves selecting appropriate evidence-based interventions. This is not the correct definition of the evaluation phase, but rather another component of the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

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