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 C

Explanation

A. Administering pain medication solely based on nonverbal cues without further assessment and confirmation of pain may lead to unnecessary medication administration and potential adverse effects.

B.Monitoring the client's nonverbal behavior is crucial in this situation because it can provide valuable insight into the client's pain experience. However, this shoudl come after listening to the client first.

C. Directly asking the client about the grimacing is a very reasonable approach. Since the client denies pain but is exhibiting nonverbal signs of discomfort, the nurse could ask specific questions to explore whether there is another underlying cause.

D. Reviewing the pain medications prescribed is important to ensure that the client is receiving appropriate pain management, but it may not be the most immediate intervention in this scenario.

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 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?

Correct Answer is C

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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