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Implementation
Implementation ( 5 Questions)
A nurse is preparing to perform a direct care intervention for a client who has a wound infection. What should the nurse do first?
Reviewing the plan of care and the prescribed treatment is the first step in the nursing process for a direct care intervention. The nurse needs to know what the goals, outcomes, and interventions are for the client before performing any action. This ensures that the nurse is following the evidence-based practice and the client's preferences. Reviewing the plan of care also helps the nurse to identify any changes or updates that might be needed based on the client's current condition.
Applying sterile gloves and cleaning the wound with saline is an important intervention for a client who has a wound infection, but it is not the first step. The nurse needs to review the plan of care and the prescribed treatment before performing any procedure to ensure that it is appropriate, safe, and effective for the client. Cleaning the wound with saline is part of the implementation phase of the nursing process, which comes after assessment, diagnosis, and planning.
Teaching the client about wound care and infection prevention is another important intervention for a client who has a wound infection, but it is not the first step either. The nurse needs to review the plan of care and the prescribed treatment before providing any education to the client. Teaching the client is also part of the implementation phase of the nursing process, which comes after assessment, diagnosis, and planning.
Documenting the wound appearance and drainage is a vital component of nursing care, but it is not the first step in a direct care intervention. The nurse needs to review the plan of care and the prescribed treatment before documenting any findings or actions. Documenting the wound appearance and drainage is part of the evaluation phase of the nursing process, which comes after assessment, diagnosis, planning, and implementation.
Choice A reason:
Reviewing the plan of care and the prescribed treatment is the first step in the nursing process for a direct care intervention. The nurse needs to know what the goals, outcomes, and interventions are for the client before performing any action. This ensures that the nurse is following the evidence-based practice and the client's preferences. Reviewing the plan of care also helps the nurse to identify any changes or updates that might be needed based on the client's current condition.
Choice B reason:
Applying sterile gloves and cleaning the wound with saline is an important intervention for a client who has a wound infection, but it is not the first step. The nurse needs to review the plan of care and the prescribed treatment before performing any procedure to ensure that it is appropriate, safe, and effective for the client. Cleaning the wound with saline is part of the implementation phase of the nursing process, which comes after assessment, diagnosis, and planning.
Choice C reason:
Teaching the client about wound care and infection prevention is another important intervention for a client who has a wound infection, but it is not the first step either. The nurse needs to review the plan of care and the prescribed treatment before providing any education to the client. Teaching the client is also part of the implementation phase of the nursing process, which comes after assessment, diagnosis, and planning.
Choice D reason:
Documenting the wound appearance and drainage is a vital component of nursing care, but it is not the first step in a direct care intervention. The nurse needs to review the plan of care and the prescribed treatment before documenting any findings or actions. Documenting the wound appearance and drainage is part of the evaluation phase of the nursing process, which comes after assessment, diagnosis, planning, and implementation.