Which outcome goals has the nurse written correctly for the postoperative client's plan of care? Select all that apply.
Client will state pain is less than or equal to a 5.
Client will state pain is less than or equal to a 4 on a 0 to 10 scale within 24 hours.
Client will have no pain.
Client will state pain is less than or equal to a 3 on a 0 to 10 scale by the time of discharge.
Client will be medicated every 4 hours by the nurse.
Correct Answer : B,D
Choice A rationale
This goal is incorrectly written because it lacks a specific timeframe for achievement. Effective outcome criteria in a nursing care plan must be SMART: specific, measurable, achievable, relevant, and time-bound. Without a deadline, the nurse cannot objectively evaluate whether the intervention was successful at a particular point in the client's recovery. While stating pain is less than or equal to 5 is measurable, the absence of a temporal component makes the goal clinically incomplete.
Choice B rationale
This is a correctly written outcome goal because it is specific and includes a clear timeframe. It identifies the subject, the measurable action using a standardized 0 to 10 pain scale, and a target window of 24 hours. Pain management is a priority postoperatively, and setting a specific threshold like 4 allows the nursing team to evaluate the effectiveness of analgesics and other comfort measures accurately within the critical early recovery period following the surgical procedure.
Choice C rationale
This goal is unrealistic and poorly defined for a postoperative client. Expecting "no pain" immediately following surgery is often unachievable due to tissue trauma and the inflammatory response. Furthermore, it lacks a timeframe for when this state should be reached. Goals must be realistic to provide a sense of progress for the patient and the healthcare team. Aiming for a manageable pain level on a numeric scale is a more evidence-based and practical nursing approach.
Choice D rationale
This goal is correctly written as it uses a measurable scale and defines a clear endpoint, which is the time of discharge. Providing a target pain level of 3 or less ensures that the patient is comfortable enough to manage activities of daily living and follow-up care at home. Using the 0 to 10 scale provides an objective way to track progress throughout the hospital stay, making it a functional part of the postoperative nursing care plan.
Choice E rationale
This statement is an intervention, not an outcome goal. An outcome goal describes a desired change in the client's status or behavior as a result of nursing care, whereas an intervention describes the actions the nurse will take. Medicating a client is something the nurse does to help reach a goal, such as reduced pain scores. Furthermore, a goal should be client-centered, focusing on the patient's response rather than the nurse's scheduled activities or tasks.
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Correct Answer is B
Explanation
Choice A rationale
While direct communication is often the first step in conflict resolution, this scenario describes a pattern of behavior that has already been addressed by others without success. The preceptor's behavior has escalated to verbal abuse and lateral violence. Simply speaking to the preceptor again is unlikely to change the behavior, as the individual has already demonstrated a lack of professional accountability. The situation requires formal intervention to protect the student and maintain a safe learning environment.
Choice B rationale
The colleague must report this behavior to the manager because it constitutes lateral violence and creates a hostile work environment. Professional standards and hospital policies typically mandate reporting of such conduct to ensure the safety of students and staff. The manager has the authority to investigate, provide formal counseling, or change the student's assignment. Addressing this at a management level ensures that the behavior is documented and that systemic steps are taken to uphold professional nursing standards.
Choice C rationale
Telling the student to "touhen up" is an inappropriate response that minimizes the impact of bullying and lateral violence. This approach places the burden of resolving a professional misconduct issue on the victim, who is in a vulnerable learning position. Such advice perpetuates a toxic culture in nursing where new members are expected to endure mistreatment. It fails to address the preceptor's unprofessionalism and does nothing to stop the cycle of abuse or ensure patient safety.
Choice D rationale
Suggesting the student request a new preceptor addresses the immediate problem for the student but fails to address the preceptor's underlying behavior. This "band-aid" fix allows the preceptor to continue mistreating future students or colleagues. While a new assignment may be necessary, it should be part of a formal process initiated by management. The colleague's responsibility is to report the unethical conduct through the proper chain of command to ensure long-term resolution and professional accountability.
Correct Answer is B
Explanation
Choice A rationale
Relying solely on the urge to urinate is often unreliable for clients requiring intermittent self-catheterization. Many of these clients have neurogenic bladders or decreased sensation, meaning they may not feel the urge until the bladder is dangerously overdistended. Overdistension can lead to urinary tract infections, vesicoureteral reflux, and permanent bladder wall damage. Therefore, a structured schedule is far safer and more effective for maintaining bladder health and preventing complications than waiting for sensation.
Choice B rationale
The frequency of intermittent self-catheterization is a highly individualized prescription based on the client's bladder capacity, fluid intake, and residual volumes. The healthcare provider determines a schedule, often every 4 to 6 hours, to ensure the bladder volume stays below a specific limit, usually 400 to 500 mL. Following a professional schedule ensures consistent drainage, prevents stasis-related infections, and protects the upper urinary tract from pressure-induced injury, making it the most appropriate instruction.
Choice C rationale
Suggesting a rigid limit of only three times a day is potentially dangerous without knowing the client's specific clinical needs. For many patients, catheterizing only three times in 24 hours would result in excessive bladder volumes, increasing the risk of leaking, infection, and kidney damage. Since urine production varies based on many factors, a fixed low frequency is rarely appropriate as a general rule. The frequency must be tailored to keep bladder volumes within safe parameters.
Choice D rationale
Every two hours is generally too frequent for the average client performing self-catheterization and can lead to unnecessary trauma to the urethral mucosa and an increased risk of introducing pathogens. Such a frequent schedule is also highly burdensome and can significantly decrease a client's quality of life and compliance. While very frequent intervals might be used in specific acute settings, it is not a standard recommendation for long-term self-management unless specifically ordered by a physician.
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