A patient develops a small sore on the sole of the left foot. The nurse notifies the physician and implements a standard care plan for impaired skin integrity. What action by the nurse would help evaluate the effectiveness of the plan?

a. Assess and document the wound condition daily.
b. Monitor and record blood glucose levels daily.
c. Assess the patient's understanding of preventive foot care.
d. Observe the patient's ability to change the dressing.


ANS: A
Evaluation must address skin integrity—assessing and documenting wound condition is the only response that does this. Monitoring glucose levels evaluates diabetes control, not skin integrity. Assessing the patient's understanding or observing a dressing change evaluates the patient's knowledge, not skin integrity.

Nursing

You might also like to view...

Subjective data differs from objective data in that subjective data is usually:

a. concretely measurable c. observable b. obtained from the client d. totally unreliable

Nursing

A nurse is performing preoperative teaching for an older adult who is scheduled to have a cata-ract extraction and lens implant. The nurse includes which of the following in the teaching plan? (Select all that apply.)

a. Avoid lifting heavy objects after the sur-gery b. Avoid bending from the waist after the surgery c. Take stool softeners as needed d. Maintain strict control of your blood sugar and blood pressure e. Maintain a dry sterile dressing over the eye for 10 days

Nursing

A home health care nurse is visiting a patient after a total hip replacement. What should the nurse include when teaching the patient how to protect the new joint?

a. Put an extension on the toilet seat. b. Keep the legs crossed when at rest. c. Frequently change positions from side to side. d. Slowly pull the knee to the chest twice a day to stretch the hip abductors.

Nursing

Which data are part of the past health history?

A) Health beliefs B) Surgeries C) Genetically linked diseases D) Age of siblings

Nursing