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Correct answer: B→C→E→A→D

(Assessment → Diagnosis → Planning → Implementation → Evaluation)

The nursing process is a systematic, step-by-step approach to delivering safe and effective patient care. The proper order of the components is Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Each step builds upon the previous one, guiding nurses from gathering data to evaluating patient outcomes, and ensuring that nursing care is organized, evidence-based, and patient-centered.

Rationale for correct answer:

2. Assessment:

The nurse begins by collecting and analyzing data about the client’s health status. This forms the foundation for all subsequent steps in the nursing process.

3. Diagnosis:

After gathering data, the nurse identifies the client’s actual or potential health problems, forming nursing diagnoses that guide care priorities.

5. Planning:

The nurse develops specific, measurable goals and selects evidence-based interventions tailored to the client’s diagnoses and overall condition.

1. Implementation:

This phase involves carrying out the planned interventions, such as administering medications, providing education, or assisting with activities of daily living.

4. Evaluation:

Finally, the nurse determines whether the client’s goals were met and assesses the effectiveness of the interventions, modifying the care plan as needed.

Take-home points:

• The correct sequence of the nursing process is Assessment, Diagnosis, Planning, Implementation, and Evaluation.
• Assessment gathers client data, and Evaluation determines if outcomes were achieved.
• Each step builds on the previous one to ensure comprehensive, client-centered care.

Rationale for correct answer:

In the Planning phase of the nursing process, nurses differentiate between outcome statements and nursing interventions. An outcome statement describes the desired result or goal that the patient will achieve, often written as SMART goals. A nursing intervention outlines the specific actions the nurse will take to help the patient meet that outcome. During planning, the nurse creates both components, ensuring that each intervention supports the achievement of the outcome.

Monitoring for potential complications

This is a nursing intervention because it involves the nurse actively observing and assessing the client for any signs of developing problems in order to prevent deterioration or manage risks early.

Changes observed in the client behavior

This is an outcome statement as it reflects how the client responds to nursing care over time, and it helps the nurse determine whether the intended health goals are being met.

Specific actions to be performed

These are nursing interventions—concrete, nurse-initiated steps taken to achieve the client’s care goals, such as administering medication, turning the patient, or teaching about diet.

Prioritized goals to be identified

This is part of the outcome planning process, where the nurse determines what improvements or targets are most important for the client to achieve during the course of care.

Expected responses to be observed

This is an outcome statement because it defines the anticipated results of nursing interventions—such as stable vital signs or pain reduction—that indicate progress toward recovery.

Take-home points:

• Nursing interventions describe what the nurse will do to help the client achieve goals, such as monitoring or performing actions.
• Outcome statements describe expected client responses or changes that result from nursing care.
• Outcome planning involves setting measurable goals that reflect the client’s health improvements or behavioral changes.

In nursing practice, actions are categorized as independent, dependent, or interdependent, reflecting the nurse’s scope of practice and collaboration with the healthcare team. Independent actions are nursing interventions initiated without a provider’s order, such as teaching or repositioning. Dependent actions require a healthcare provider’s prescription, such as administering medications. Interdependent actions involve collaboration with other disciplines, like coordinating physical therapy.

Rationale for correct answer:

Administering medications

This is a dependent nursing action because it requires a prescription or order from a licensed healthcare provider. Nurses carry out the administration, but they do not independently choose the medication.

Educating a client on discharge medications

This is an independent action within the nurse’s scope of practice. Nurses can independently provide teaching on medication usage, timing, and side effects to ensure client understanding and promote safe self-care after discharge.

Documenting the client’s response to a medication

This is an independent nursing action since nurses are responsible for observing, recording, and reporting client outcomes related to medications. It is a critical part of ongoing clinical assessment and care evaluation.

Consulting the pharmacist about a medication order

This is an interdependent action involving collaboration between the nurse and pharmacist. Nurses consult pharmacists to clarify, verify, or adjust medication orders to ensure safe and accurate drug administration.

Discussing with the healthcare provider the client’s medication change request

This is also an interdependent action, requiring collaborative communication with the provider. Nurses advocate for client concerns and help ensure that care decisions reflect client needs while staying within legal practice boundaries.

Take-home points:

• Dependent actions require a provider’s prescription, while independent actions fall within the nurse’s autonomous scope.
• Interdependent actions involve collaboration with healthcare team members like providers or pharmacists.
• Nurses independently educate and document, but consult and medication administration rely on orders or teamwork.

The nursing process is a systematic, patient-centered framework used to deliver safe and effective care. It consists of five steps: Assessment, where the nurse collects and analyzes patient data; Diagnosis, identifying actual or potential patient responses to health problems; Planning, setting measurable goals and selecting interventions; Implementation, performing the planned nursing actions; and Evaluation, determining whether the patient goals were met and revising the care plan as needed.

Rationale for correct answer:

Assessment → Take a drug history

In the assessment phase, nurses gather comprehensive information, including a detailed drug history. This helps identify current medications, potential interactions, allergies, and baseline client data essential for safe care.

Diagnosis → Analysis of the client data to determine client need

During diagnosis, the nurse critically analyzes assessment data to identify actual or potential health issues, including medication-related problems. This guides formulation of appropriate nursing diagnoses to direct care.

Planning → Determine client education needed for medication side effects

In the planning phase, nurses set goals and choose appropriate actions, including teaching the client about possible side effects. This ensures the client is informed, safe, and prepared to manage their medications after discharge.

Interventions → Identify the client and administer medications

This step involves executing planned nursing actions, such as correctly identifying the client using two identifiers and safely administering medications according to standards and provider orders.

Evaluation → Identify the therapeutic intent of the medication

In evaluation, the nurse determines whether the expected outcomes of medication therapy have been achieved. Understanding the therapeutic intent helps assess if the medication is effective or if adjustments are needed.

Take-home points:

• Assessment involves collecting data like drug history to form the foundation of the care plan.
• Planning includes determining client education needs, while interventions involve safely administering medications.
• Evaluation focuses on assessing the medication’s therapeutic intent to determine if goals are met.