Nursing Process

EXPLANATION

✔Correct answer:

Ensure pain intensity is reported as 3 or lower throughout the hospital stay. This option represents a suitable patient-focused goal, as it is specific, measurable, and time-bound. It addresses the nursing diagnosis of acute pain and outlines a clear objective (keeping pain intensity at a manageable level) that can be evaluated during the patient's hospital stay.

✘Incorrect answer options:

Educate the patient about non-pharmacological pain management techniques. While this option is an important nursing intervention, it does not represent a patient-focused goal. It is an action that the nurse will take to help the patient manage their pain, but it does not provide a specific, measurable outcome.

Evaluate the impact of pain intensity on patient functionality. This option is more focused on assessment and evaluation rather than establishing a patient-focused goal. It is important to consider the impact of pain on the patient's functionality, but it does not provide a clear, measurable objective related to pain management.

Provide pain relief medication 30 minutes prior to physical therapy sessions. This option is a nursing intervention, not a patient-focused goal. It describes a specific action that the nurse will take to help manage the patient's pain but does not outline a measurable outcome for the patient's pain management.

EXPLANATION

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Elevating the leg 5 inches above the heart level. This independent nursing intervention is appropriate for a patient with a fractured right tibia. Elevating the affected limb above the heart level can help reduce swelling and promote circulation, which may aid in the healing process. As an independent intervention, the nurse does not need a healthcare provider's order to perform this action.

✘Incorrect answer options:

Encouraging the patient to bear weight on the injured leg to build strength. This option is not an appropriate independent nursing intervention for a patient with a fractured right tibia. Bearing weight on the injured leg may cause further harm and hinder the healing process. Weight-bearing and other activities should be guided by the healthcare provider based on the patient's specific condition and progress.

Carrying out a range of motion exercises for the right leg every 4 hours. While a range of motion exercises may be beneficial for some patients, they should be performed only when advised by a healthcare provider. In a patient with a fractured right tibia, a range of motion exercises could cause further harm or exacerbate the injury.

Administering aspirin 325 mg every 4 hours as required. This option is not an independent nursing intervention, as administering medication requires a healthcare provider's order. Nurses cannot prescribe or administer medications without an order from a licensed healthcare provider.

EXPLANATION

✔Correct answer:

Understands the available resources from the healthcare facility, the patient's family, and the patient themselves. In the process of setting achievable goals, a nurse should consider the available resources from the healthcare facility, the patient's family, and the patient themselves. This understanding helps the nurse develop realistic and attainable goals that can be supported by the available resources. It also ensures that the goals are tailored to the patient's specific needs, preferences, and circumstances, ultimately leading to better patient outcomes and satisfaction.

✘Incorrect answer options:

Develops goals grounded in their own expertise. While a nurse's expertise is valuable in the goal-setting process, it is essential to collaborate with the patient, their family, and other members of the healthcare team to develop goals that are truly patient-centered and take into account the unique needs and preferences of the patient.

Ensures the patient is both physically and emotionally stable. While it is important to consider the patient's physical and emotional stability when setting goals, it is not always possible or necessary for the patient to be completely stable before setting goals. In many cases, the process of setting and working towards goals can contribute to the patient's overall stability and recovery.

Relies solely on standardized care plans without customization. Standardized care plans can provide a helpful starting point, but it is essential to customize them based on the patient's unique needs, preferences, and circumstances. This individualized approach ensures that the care plan is tailored to the patient and leads to better patient outcomes and satisfaction.

EXPLANATION

✔Correct answer:

Understanding, role-specific capabilities, and specialized techniques. In order to effectively implement an intervention, a nurse needs proficiency in three domains: understanding, role-specific capabilities, and specialized techniques. Understanding refers to the nurse's ability to comprehend the rationale and evidence behind a given intervention. Role-specific capabilities pertain to the skills and competencies that are specific to the nurse's role and scope of practice. Specialized techniques encompass the technical skills and knowledge required to perform certain interventions safely and effectively.

✘Incorrect answer options:

Practical experience, higher education, and a diverse skill set. While these factors can contribute to a nurse's overall competence, they do not specifically address the domains required for effectively implementing interventions.

Technical abilities, financial management, and leadership qualities. While technical abilities are important for implementing interventions, financial management and leadership qualities are not directly related to the effective execution of nursing interventions.

Leadership capacity, independence, and a range of skills. Leadership capacity and independence may be important aspects of a nurse's overall professional development, but they do not directly address the domains required for effectively implementing nursing interventions.

EXPLANATION

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Be knowledgeable and adhere to established standards of practice from nursing and other disciplines. While formulating goals, outcomes, and interventions, the nurse must be knowledgeable and adhere to established standards of practice from nursing and other disciplines. This ensures that the care plan is based on the best available evidence and guidelines, which ultimately leads to better patient outcomes and a higher quality of care.

✘Incorrect answer options:

Oversee all aspects of care and planning for the patient. While the nurse plays a significant role in developing the care plan, it is essential to collaborate with the patient, their family, and other members of the healthcare team to ensure a comprehensive and coordinated approach to care.

Avoid modifying the patient's care plan. On the contrary, the nurse should be prepared to modify the care plan as needed based on the patient's progress, changes in their condition, or new information. Regular evaluation and modification of the care plan ensure that the patient's needs are being met and that the care provided is appropriate and effective.

Disregard the patient's preferences and expectations. It is essential to consider the patient's preferences and expectations when developing the care plan. Taking their input into account helps ensure that the plan is tailored to their needs and desires, which can lead to better patient satisfaction and outcomes.

EXPLANATION

✔Correct answer:

Lynda Hall. Lynda Hall, a British nurse, first coined the term "nursing process" in 1955. She introduced the concept with its three initial steps: Observation, Ministration, and Validation. Over time, the nursing process has evolved into a systematic and dynamic approach to patient care that includes assessment, diagnosis, planning, implementation, and evaluation.

✘Incorrect answer options:

Virginia Henderson. While Virginia Henderson was an influential nursing theorist who contributed significantly to nursing knowledge, she did not coin the term "nursing process." Henderson is best known for her Nursing Need Theory, which defines nursing as assisting individuals in performing activities contributing to health or recovery (or a peaceful death).

Jean Watson. Jean Watson is known for her Theory of Human Caring, which emphasizes the importance of caring in the nursing profession. Although her work has made a significant impact on nursing practice, she did not coin the term "nursing process."

Martha Rogers. Martha Rogers developed the Science of Unitary Human Beings, a nursing theory that views individuals as irreducible wholes in constant interaction with their environment. Rogers did not coin the term "nursing process."

EXPLANATION

✔Correct answer:

All of the choices. Appropriately developed, patient-focused objectives ought to address the immediate needs of the patient, incorporate preventative healthcare measures, and take into account rehabilitation requirements. By considering all these aspects, the nurse can develop a comprehensive and holistic care plan that meets the patient's unique needs, promotes optimal health and well-being, and facilitates the patient's recovery and return to their daily activities.

EXPLANATION

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Optimal level of well-being and self-sufficiency in functioning. A patient-centered goal represents a precise and quantifiable behavior or response that demonstrates a patient's optimal level of well-being and self-sufficiency in functioning. These goals are established during the planning phase of the nursing process and are based on the patient's needs, preferences, and abilities. They serve as benchmarks for evaluating the effectiveness of nursing interventions and help guide the nurse in providing the best possible care.

✘Incorrect answer options:

Preference for particular healthcare interventions. While a patient's preferences should be considered when developing a care plan, patient-centered goals focus on the desired outcomes, not the specific interventions themselves. Interventions should be chosen based on their ability to help the patient achieve their goals.

Doctor's objective for the specific patient. While the physician's objectives may align with the patient-centered goals, the goals are primarily focused on the patient's optimal well-being and self-sufficiency in functioning from a nursing perspective. The nurse should collaborate with the physician and other members of the healthcare team to ensure a comprehensive and coordinated care plan, but patient-centered goals are developed within the context of nursing care.

Family's expectations for the patient's progress. While the family's expectations may be considered when developing a care plan, patient-centered goals are primarily focused on the patient's needs, preferences, and abilities. The goals should be realistic and attainable, and the nurse should work with the patient and their family to develop a shared understanding of the desired outcomes.

EXPLANATION

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Patient-focused objectives and anticipated outcomes are set. In the planning phase of nursing actions, the nurse develops a comprehensive care plan based on the patient's needs and issues identified during the assessment and diagnosis phases. This plan includes patient-focused objectives and anticipated outcomes, which serve as benchmarks for evaluating the effectiveness of the nursing interventions and the patient's progress toward their goals.

✘Incorrect answer options:

The nurse identifies the healthcare requirements of the patient. This occurs during the assessment phase of the nursing process, where the nurse gathers data from the patient, including conducting a physical examination, reviewing medical history, and interviewing the patient and their family. This information is then used to determine the nursing diagnoses and develop the care plan in the planning phase.

The nurse documents the patient's progress. While documenting the patient's progress is an essential part of nursing care, it occurs during the evaluation phase of the nursing process. The evaluation phase focuses on comparing the patient's progress against the established objectives and anticipated outcomes, making necessary adjustments to the care plan, and documenting the patient's progress.

The patient determines their necessary care. Although patient involvement is crucial in developing a nursing care plan, it is the nurse's responsibility to determine the necessary care based on the assessment and diagnosis phases. The patient should be included in the planning phase, and their preferences and goals should be taken into account, but the nurse ultimately develops the care plan using their professional judgment and evidence-based practice.

EXPLANATION

✔Correct answer:

Discontinuing physical therapy sessions over the weekend. A variance analysis in the context of critical paths refers to identifying deviations from the expected plan of care that may affect the patient's outcomes. Discontinuing physical therapy sessions over the weekend represents a deviation from the expected care plan and may lead to delayed recovery or other complications. This situation warrants further investigation to understand the reasons for discontinuation and take appropriate action to ensure continuity of care.

✘Incorrect answer options:

A patient's family participating in a diabetes education session. This situation does not require further action or investigation, as it is an expected part of the care plan that contributes to improved patient outcomes and self-management of diabetes.

A patient's wound heals at an expected rate. This situation indicates that the care plan is being followed appropriately and the patient is progressing as expected. No further action or investigation is needed.

A patient displaying proper medication administration after receiving instruction. This situation demonstrates effective patient education and adherence to the care plan, which should lead to improved patient outcomes. No further action or investigation is needed.

EXPLANATION

✔Correct answer:

3, 4, 1, 2. The correct order of priority for the identified nursing diagnoses is as follows:

1. Inadequate airway clearance (3) – This is the highest priority, as maintaining a patent airway is essential for life. Compromised airway clearance can lead to respiratory failure and poses an immediate threat to the patient's life.
2. Insufficient tissue perfusion (4) – This is the second priority, as inadequate tissue perfusion can lead to organ damage and eventual organ failure. Ensuring adequate perfusion is crucial for maintaining the patient's overall health and preventing complications.
3. Constipation (1) – This is the third priority. Although constipation can cause discomfort and complications if not managed, it is less critical than airway clearance and tissue perfusion.
4. Expected grieving (2) – This is the lowest priority. While addressing the emotional needs of the patient is essential, the physiological needs must be addressed first to ensure the patient's safety and well-being.

✘Incorrect answer options:

1, 4, 2, 3. This order incorrectly places constipation as the highest priority and airway clearance as the lowest priority.

2, 4, 3, 1. This order incorrectly places expected grieving as the highest priority and constipation as the lowest priority.

3, 2, 1, 4. This order incorrectly places expected grieving as a higher priority than insufficient tissue perfusion.

EXPLANATION

✔Correct answer:

Alerting the physician immediately. Nurse Williams' first consideration in addressing the deteriorating wound situation should be to alert the physician immediately. The physician is responsible for assessing the situation, making a diagnosis, and prescribing the appropriate treatment plan. If the current treatment is not working, it may require a change in medication, additional diagnostic tests, or other medical interventions that only the physician can order.

The collaboration between nurses and physicians is vital for patient care. Nurses are often the first to notice changes in a patient's condition, and they have a professional and ethical responsibility to report these changes to the physician promptly. This collaboration ensures that the patient receives timely and appropriate care.

Imagine a car that starts making a strange noise. While you might have some ideas about what's wrong, you would take it to a mechanic because they have the expertise to diagnose and fix the problem. Similarly, Nurse Williams might have observations and insights about the wound, but the physician has the medical expertise to diagnose and treat the underlying issue.

✘Incorrect answer options:

Reaching out to the wound care nurse. While consulting with a wound care nurse might be a valuable step later in the process, the immediate priority is to alert the physician. The physician needs to be informed of the situation as they have the authority and expertise to make changes to the treatment plan.

Altering the wound care treatment on her own. Nurses must work within the scope of their practice and follow the treatment plan prescribed by the physician. Altering the wound care treatment on her own would be outside Nurse Williams' scope of practice and could potentially harm the patient.

Seeking advice from another nurse on duty. While seeking advice from a colleague can be helpful in some situations, the priority in this case is to alert the physician. The physician has the medical expertise to assess the situation and make necessary changes to the treatment plan.

EXPLANATION

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Patients will report pain intensity below 4 on a 0-10 scale. When composing an expected outcome statement in quantifiable terms, a nurse should include specific, measurable criteria that can be used to evaluate the effectiveness of nursing interventions. In this example, the nurse has set a clear and measurable goal for pain management, which allows for easy evaluation of the patient's progress and the success of the nursing interventions in addressing the patient's pain.

✘Incorrect answer options:

Patients will experience reduced pain. While this statement describes a desired outcome, it is not quantifiable. It does not provide specific, measurable criteria to evaluate the success of nursing interventions in addressing the patient's pain.

Patients will demonstrate pain-relief techniques. This statement focuses on the patient's actions rather than a specific, measurable outcome related to pain management. While it is important for patients to learn and demonstrate pain-relief techniques, the statement does not provide a clear, quantifiable goal for pain management.

Patients will take pain medication every 4 hours consistently. This statement focuses on the patient's actions regarding medication administration rather than a specific, measurable outcome related to pain management. While consistent medication use is important for effective pain management, the statement does not provide a clear, quantifiable goal for evaluating the patient's pain experience.

EXPLANATION

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Expected outcomes. The statements "Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile" serve as examples of expected outcomes in a nursing care plan for a patient following a mastectomy. Expected outcomes are specific, measurable, and time-bound statements that describe the anticipated results of nursing interventions. In this case, the expected outcomes focus on the healing of the incision site and the prevention of infection, which are clear and measurable objectives that can be used to evaluate the effectiveness of the nursing care provided.

✘Incorrect answer options:

Assessment criteria. Assessment criteria are the standards or benchmarks used to evaluate a patient's condition, needs, or response to treatment. The given statements describe the desired results of nursing interventions, not the criteria used for assessment.

Short-term objectives. Short-term objectives are smaller, achievable goals that can be accomplished within a relatively short time frame. Although the given statements may be achieved in the short term, they are more appropriately categorized as expected outcomes rather than short-term objectives.

Long-term objectives. Long-term objectives are broader goals that are expected to be achieved over a more extended period. The given statements are specific and time-bound, making them more suitable as expected outcomes rather than long-term objectives.

EXPLANATION

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A written framework for implementation and assessment. The nursing care plan serves as a written framework for implementing nursing interventions and assessing their effectiveness. It is a comprehensive document that outlines the patient's care, including nursing diagnoses, goals, interventions, and expected outcomes. The nursing care plan guides the nurse in providing individualized, patient-centered care and helps to ensure that the care provided is evidence-based, consistent, and well-coordinated among healthcare team members.

✘Incorrect answer options:

A method for identifying gaps in care delivery. While a nursing care plan may help identify gaps in care delivery, its primary purpose is to provide a written framework for implementing and assessing nursing interventions.

A forecast of possible changes in patient behaviors. The nursing care plan does not serve as a forecast of possible changes in patient behaviors. Instead, it is a tool for guiding the nurse in providing care based on the patient's current needs, health status, and established goals.

An instrument for setting objectives and anticipating outcomes. Although setting objectives and anticipating outcomes are important components of a nursing care plan, the primary purpose of the care plan is to provide a written framework for implementing and assessing nursing interventions.

EXPLANATION

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Be alert and possess a certain level of autonomy. To actively engage in goal setting, patients should be alert and possess a certain level of autonomy. This enables them to effectively communicate their needs, preferences, and concerns with the healthcare team, as well as participate in decision-making about their care. Collaborative goal-setting ensures that the nursing care plan is tailored to the patient's specific needs and desires, leading to better outcomes and increased patient satisfaction.

✘Incorrect answer options:

Have the ability to move around and be ambulatory. While physical mobility can be helpful, it is not a requirement for patients to actively engage in goal setting. Patients with limited mobility can still participate in the process by discussing their needs, preferences, and concerns with the healthcare team.

Be capable of speaking and writing. Although the ability to speak and write can be beneficial for communication, it is not a requirement for patients to actively engage in goal setting. Alternative methods of communication, such as non-verbal cues or assistive devices, can be used to facilitate patient participation in the process.

Demonstrate a basic understanding of their medical condition. While having a basic understanding of their medical condition can help patients make informed decisions about their care, it is not a requirement for actively engaging in goal setting. The nurse and other healthcare professionals can provide education and support to help patients understand their condition and the available treatment options.

EXPLANATION

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Collaborating and evaluating the recommended approaches with the CNS. The primary nurse is responsible for working together with the clinical nurse specialist (CNS) to assess and implement the suggested strategies for managing complex nursing issues. This collaboration ensures that the best possible care is provided to the patient, based on evidence-based practice and expert knowledge.

✘Incorrect answer options:

Executing the recommendations provided by the specialist. Although the primary nurse should consider the recommendations provided by the CNS, it is essential to collaborate and evaluate these suggestions to ensure they are appropriate and tailored to the specific patient's needs.

Disregarding the suggestions if they conflict with personal opinions. It is unprofessional and potentially harmful to disregard expert advice based solely on personal opinions. The primary nurse should collaborate with the CNS and other healthcare professionals to provide the best care for the patient, based on evidence and best practices.

Explaining the proposed strategies to the patient and their family members. While it is important to communicate with the patient and their family members, the primary nurse's responsibility is to collaborate with the CNS to evaluate and implement the recommended approaches. Once an appropriate plan is agreed upon, the primary nurse can then explain the strategies to the patient and their family members.

EXPLANATION

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Expected outcome. The statement "The client will remain free from infection throughout hospitalization" exemplifies an expected outcome. Expected outcomes are specific, measurable, and time-bound statements that describe the anticipated results of nursing interventions. In this case, the expected outcome is that the immunosuppressed patient will not develop an infection during their hospital stay, which is a clear and measurable objective that can be used to evaluate the effectiveness of the nursing care provided.

✘Incorrect answer options:

Treatment plan. A treatment plan is a comprehensive outline of the patient's care, including diagnoses, goals, interventions, and expected outcomes. The given statement is a specific expected outcome rather than a complete treatment plan.

Short-term goal. Short-term goals are smaller, achievable objectives that can be accomplished within a relatively short time frame. While the given statement is time-bound (throughout hospitalization), it is more appropriately categorized as an expected outcome rather than a short-term goal.

Long-term goal. Long-term goals are broader objectives that are expected to be achieved over a more extended period. The given statement is specific and time-bound to the patient's hospitalization, making it more suitable as an expected outcome rather than a long-term goal.

EXPLANATION

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Duration for which the current treatment has been administered. When reaching out to a nursing consultant regarding a challenging patient-centered issue, the primary nurse should communicate relevant clinical information that will help the consultant understand the situation and provide appropriate guidance. This includes the duration for which the current treatment has been administered, as it offers essential context about the patient's response to the treatment and the effectiveness of the intervention.

✘Incorrect answer options:

The partner's response to the patient's dressing alteration. While the partner's response might provide some insight into the patient's support system, it is not the most critical information to share with a nursing consultant when seeking advice on a challenging issue.

Patient's apprehension about the ongoing treatment. Although the patient's feelings are important, the primary focus should be on providing the consultant with clinical information relevant to the patient's condition and treatment progress.

Doctor's hesitance to modify the existing treatment plan. While the doctor's perspective might be informative, the main focus should be on sharing specific details about the patient's condition and response to the treatment plan. The nursing consultant can then provide guidance based on their expertise and knowledge of best practices.

EXPLANATION

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A team of various healthcare specialists. Collaborative interventions necessitate the involvement of a team of various healthcare specialists, such as physicians, nurses, therapists, dietitians, pharmacists, and other healthcare professionals. These interventions require a coordinated and interdisciplinary approach to provide comprehensive and effective care to the patient. By working together, the healthcare team can develop a care plan that addresses the patient's unique needs and leverages the expertise of each specialist to optimize patient outcomes.

✘Incorrect answer options:

Both doctors and nurses in the intervention process. While doctors and nurses are essential members of the healthcare team, collaborative interventions involve more than just these two professionals. Other healthcare specialists also contribute their expertise to ensure a comprehensive and coordinated approach to care.

The combined efforts of nurses and clients. Although the collaboration between nurses and clients is important in the care process, collaborative interventions specifically refer to the involvement of multiple healthcare specialists working together to address the patient's needs.

Support from administrative and healthcare staff. While administrative and healthcare staff can play a supportive role in the care process, collaborative interventions specifically involve the coordinated efforts of various healthcare specialists who contribute their unique expertise to provide comprehensive care to the patient.

EXPLANATION

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Problem severity. The process of prioritizing assists nurses in anticipating and organizing nursing interventions for patients with multiple issues or alterations. Priorities are determined based on the patient's problem severity to ensure that the most urgent or life-threatening issues are addressed first. This approach allows the nurse to allocate time and resources effectively and provide the best possible care to the patient.

✘Incorrect answer options:

Attending physician. While the attending physician plays a significant role in the overall care of the patient, the nurse is responsible for determining priorities within the nursing care plan. The nurse should collaborate with the physician and other members of the healthcare team to ensure comprehensive and coordinated care, but the prioritization of nursing interventions is primarily the nurse's responsibility.

Personal preferences. Although the patient's personal preferences should be taken into account during the planning and implementation of nursing care, they are not the primary factor in determining priorities. The nurse must consider the severity of the patient's problems and prioritize interventions accordingly to provide the most effective and timely care.

Long-term well-being. While the long-term well-being of the patient is important, the immediate priority in nursing care is to address the most severe or life-threatening problems. As the patient's condition stabilizes, the nurse can then focus on interventions that promote long-term well-being and recovery.

EXPLANATION

✔Correct answer:

Establishing goals and choosing interventions. In the planning phase of the nursing process, the primary activities involve establishing patient-centered goals and choosing appropriate nursing interventions to help the patient achieve these goals. This phase builds on the information gathered during the assessment phase and the nursing diagnoses made. By developing specific, measurable, and achievable goals and selecting interventions tailored to the patient's needs, nurses can create a comprehensive care plan that promotes the patient's health and well-being.

✘Incorrect answer options:

Assessment and diagnosis. Assessment and diagnosis are separate phases of the nursing process that precede the planning phase. Assessment involves gathering information about the patient's health status, while diagnosis involves identifying the patient's actual or potential health problems based on the assessment data.

Evaluation of goal attainment. Evaluation of goal attainment is part of the evaluation phase of the nursing process, which occurs after the implementation of interventions. During this phase, nurses assess the patient's progress toward achieving the established goals and adjust the care plan as needed.

Identifying and addressing barriers to care. Identifying and addressing barriers to care may be a part of the assessment, diagnosis, or intervention phases of the nursing process, but it is not the primary focus of the planning phase.

EXPLANATION

✔Correct answer:

Raise the head of the bed to a 30-degree angle before meals. This intervention is specific, measurable, and clearly outlines an action the nurse will take to facilitate the patient's comfort and safety during meals.

✘Incorrect answer options:

Utilize continuous passive motion machines throughout the day. This intervention is not specific enough, as it does not provide clear guidance on how often or for how long the continuous passive motion machine should be used. A more appropriate intervention would specify the frequency and duration of use.

Conduct regular neurovascular assessments. Although this intervention seems appropriate, it lacks specificity regarding the frequency of the assessments. An appropriately written intervention would state how often the assessments should be conducted, such as "Conduct neurovascular assessments every 2 hours."

Replace dressings once per shift. This intervention is vague, as it does not specify which dressings should be replaced, the type of dressing to be used, or the appropriate technique for replacing the dressing. A more appropriate intervention would provide these details, such as "Replace the sterile gauze dressing over the surgical incision once per shift, using aseptic technique."

Well-written nursing interventions should be clear, concise, and specific, providing guidance on the actions to be taken by the nurse in caring for the patient.

EXPLANATION

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A patient exhibiting a fever, sweating profusely, and appearing restless. The RN should prioritize creating a care plan for this patient first, as these symptoms indicate that the patient may be experiencing an acute issue requiring immediate intervention. Fever, profuse sweating, and restlessness can be signs of infection, pain, or other serious conditions that need prompt assessment and management to prevent complications and ensure the patient's well-being.

✘Incorrect answer options:

A patient scheduled for a routine check-up later in the day. While a care plan should be created for this patient, it is not the highest priority since the patient is stable and the check-up is routine.

A patient scheduled for occupational therapy at 1300. Although the patient will need a care plan in place for the occupational therapy session, it is not the highest priority since the patient's condition is stable, and the therapy session is scheduled later in the day.

A patient who recently underwent an appendectomy and has just been administered pain medication. While the patient will require monitoring and a care plan, the fact that they have just received pain medication suggests that their immediate needs have been addressed. The RN should prioritize the patient with acute symptoms.

EXPLANATION

✔Correct answer:

Formulate a plan for nursing care. Evaluating a patient's condition and determining nursing diagnoses allows a nurse to develop an appropriate plan of nursing care tailored to the patient's specific needs and issues. The plan of care should include specific interventions, goals, and evaluation criteria based on the identified nursing diagnoses.

✘Incorrect answer options:

Initiate a physical examination. A physical examination is part of the assessment phase of the nursing process, which precedes the evaluation of the patient's condition and determination of nursing diagnoses. Initiating a physical exam would have likely already been completed before determining nursing diagnoses.

Establish a priority list. Although establishing a priority list can be helpful in organizing the nursing care plan, it is not necessarily the immediate next step following the determination of nursing diagnoses. The priority list can be integrated into the nursing care plan to ensure that the most urgent needs are addressed first.

Conduct a reassessment of the client's condition. Reassessing the patient's condition should be an ongoing part of providing nursing care but is not the immediate next step after determining nursing diagnoses. After formulating the nursing care plan, the nurse should implement the interventions and then reassess the patient's condition to evaluate the effectiveness of the care and make any necessary adjustments.