The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations:
a. must be done at the end of every shift.
b. should be done at least every 24 hours.
c. depend on intervention and patient condition.
d. are always done at time of discharge.
ANS: C
In most cases, goal statements need to include a time for evaluation. The time depends on the intervention and the patient's condition. Some goals may need to be evaluated daily or weekly, and others may be evaluated monthly. The health care setting affects the time of evaluation. If the goal is set during hospitalization, the goal may need to be evaluated within days, whereas a goal set for home care may be evaluated weekly or monthly. At the time of evaluation, the goal is assessed for goal attainment, and new goals are set or a new evaluation date for the same goal may be chosen if the goal is still applicable for the patient care plan.
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Information in the critical pathway
A) provides nursing actions to help the patient achieve the goals. B) is for critical care providers in the event of an emergency. C) does not pertain to nursing assistant care. D) is completed and logged upon hospital discharge.
The nurse is caring for a patient experiencing epistaxis. What action should the nurse take first?
a. Obtain the patient's vital signs. b. Firmly pack the nostrils with gauze. c. Apply a cold compress. d. Instruct the patient to sit forward and pinch the nose below the bone.
When examining the mouth of a client, the nurse notes a bluish-black line along the gum line. Which action would be the priority?
A) Determining whether the client is receiving phenytoin therapy B) Referring the client for further evaluation C) Encouraging the client to enroll in a smoking cessation program D) Providing the client with information on proper mouth care
Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following?
A) 1+ B) 2+ C) 3+ D) 4+