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 D

Explanation

D. The short, rattling, high-pitched sounds heard in the lower lobes of the client with pneumonia are indicative of crackles. Crackles are abnormal respiratory sounds that occur when air moves through fluid or mucus in the small airways or alveoli.

A. Stridor refers to a high-pitched, wheezing sound that occurs during inspiration or expiration and is typically associated with upper airway obstruction, such as in conditions like croup or foreign body aspiration.

B. Pleural rub refers to a grating or rubbing sound heard on auscultation that occurs when inflamed pleural surfaces rub against each other during respiration. It is commonly heard in conditions such as pleurisy or pleural effusion.

C. Wheezing refers to a high-pitched, musical sound heard during expiration that is typically associated with narrowing or obstruction of the airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD).

Correct Answer is ["10"]

Explanation

To calculate the volume in mL to administer, use the formula:

Volume(mL) = Prescribeddose(mg)/Availableconcentration(mg/mL)

Step 1: Convert the prescribed dose to milligrams
The prescribed dose is 5 grams.

Convert grams to milligrams:

5 grams × 1000 mg/gram = 5000 mg

Step 2: Divide by the concentration
The available concentration is 500 mg/mL.

Calculate the volume:

Volume(mL) = 5000 mg / 500 mg/mL = 10 mL

The nurse should administer 10 mL.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Correct Answer is D

Explanation

The healthcare provider prescribes cefuroxime 5 grams every 8 hours IM for a client with pneumonia. The available vial is labeled, "Cefuroxime 500 mg/mL." How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required round to the nearest whole number.)

Correct Answer is ["10"]

Explanation

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