When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Compare the client's manifestations with the defining criteria of related problems.

Review the priority nursing problems included in the plan of care.

List the nursing actions that need to be implemented most immediately.

Ensure that all treatments prescribed by the healthcare provider have been initiated.

Answer and Explanation

The Correct Answer is B

A. When identifying goals to be included in a client's plan of care, the nurse should compare the client's manifestations (signs and symptoms) with the defining criteria of related nursing problems or diagnoses. This involves assessing the client's current health status, identifying specific problems or areas of concern, and determining desired outcomes or goals for improvement.

B. Reviewing the priority nursing problems already included in the plan of care helps the nurse understand the client's current status and ongoing care needs. However, this may leave out other client needs not stated as priority

C. While listing immediate nursing actions is important for addressing urgent care needs, it does not directly address the process of identifying goals for the client's plan of care.

D. Ensuring that prescribed treatments have been initiated is an important aspect of client care, but it pertains more to implementation rather than goal identification.

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Correct Answer is ["B","C","D","E"]

Explanation

Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determine its antibiotic susceptibility, guiding appropriate treatment.

C. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess for signs of infection and the body's immune response to the MRSA infection.

D. Use standard precautions and wear a mask.

Standard precautions should always be followed to prevent the transmission of infections in healthcare settings. Wearing a mask may be indicated if there is a risk of respiratory droplet transmission during wound care or other procedures.

E. Institute contact precautions for staff and visitors.

Contact precautions should be implemented to prevent the spread of MRSA to others. This includes wearing gloves and gowns when providing care, as well as educating staff and visitors about proper hand hygiene and infection control measures.

A. Uses an oral airway to keep the teeth apart. B. Places the client in a supine position. C. Tests for a gag reflex before performing oral care. D. Suctions secretions from the posterior pharynx.

Correct Answer is B

Explanation

A. Using an oral airway can be appropriate in some situations to keep the mouth open and facilitate oral care, especially in an unconscious client. This helps prevent biting and allows for easier access to the oral cavity. Therefore, this action does not indicate a need for additional training.

B. Placing an unconscious client in a supine position for oral care can be inappropriate, as it increases the risk of aspiration, especially if there are secretions in the mouth. It is generally safer to position the client in a lateral position to minimize this risk. This action may indicate a need for additional training.

C. Testing for a gag reflex before performing oral care is a standard precaution, especially for unconscious clients. This helps prevent aspiration and ensures the safety of the client during the procedure.

D. Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration, especially for unconscious clients who may have difficulty managing their secretions.

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When identifying the goals to be included in a client's plan of care, the nurse should take which action?

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Naxlex Comprehensive Predictor Exams

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin- resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is B

Explanation

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

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A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? Select all that apply.

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.