A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?

Planning

Evaluation

Data collection

Implementation

Answer and Explanation

The Correct Answer is A

Choice A reason: This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
Choice B reason: This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
Choice C reason: This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
Choice D reason: This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.

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Correct Answer is C

Explanation

Choice A reason: Irrigating and performing a dressing change for a client who has a pressure injury wound is not a task that the nurse should delegate to an AP. This task requires the nurse's clinical judgment, skill, and knowledge to assess the wound, select the appropriate dressing, and prevent infection. This task is also within the nurse's scope of practice, but not the AP's scope of practice.

Choice B reason: Administering oral PRN pain medication to a client who has arthritis is not a task that the nurse should delegate to an AP. This task involves the nurse's responsibility to evaluate the client's pain level, determine the need and the dosage of the medication, and monitor the client's response and side effects. This task is also within the nurse's scope of practice, but not the AP's scope of practice.

Choice C reason: Obtaining a daily weight on a client who has heart failure is a task that the nurse can delegate to an AP. This task is a routine and standardized procedure that does not require the nurse's clinical judgment, skill, or knowledge. This task is also within the AP's scope of practice, if the nurse provides clear directions and supervision.

Choice D reason: Reinforcing teaching the use of an incentive spirometer to a postoperative client is not a task that the nurse should delegate to an AP. This task involves the nurse's role to educate the client about the purpose, benefits, and technique of using the incentive spirometer, and to evaluate the client's understanding and compliance. This task is also within the nurse's scope of practice, but not the AP's scope of practice.

A. "An example of a sentinel event is administering incompatible blood products to a client." B. "An example of a sentinel event is administering client medications 30 minutes late." C. "An example of a sentinel event is documenting vital signs at the wrong time in the client’s electronic health record." D. "An example of a sentinel event is administering a prescribed sedative to a client for insomnia."

Correct Answer is A

Explanation

Choice A reason: A sentinel event is a serious adverse event that results in death, permanent harm, or severe temporary harm to a patient. Administering incompatible blood products to a client is a sentinel event because it can cause fatal hemolytic reactions.

Choice B reason: Administering client medications 30 minutes late is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Medication errors are common and preventable, and they should be reported and analyzed to improve patient safety.

Choice C reason: Documenting vital signs at the wrong time in the client’s electronic health record is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Documentation errors are also common and preventable, and they should be corrected and avoided to ensure accurate and timely information.

Choice D reason: Administering a prescribed sedative to a client for insomnia is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Sedatives are commonly used to treat insomnia, and they should be prescribed and administered with caution and monitoring⁵.

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A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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