A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?

Question

a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics
b. Completing an interview and physical examination before adding a nursing diagnosis
c. Developing nursing diagnoses before completing the database
d. Including cultural and religious preferences in the database

Answer 1

ANS: C
Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse. Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview and physical examination before adding a nursing diagnosis is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.