The written goal statement in a client's care plan is: Client will have clear lung sounds bilaterally within 3 days
One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:
1. Ask how many times per day the client practiced the coughing and deep breathing exercises.
2. Tell the client that the lungs are clear.
3. Document the assessment findings to show the effectiveness of the intervention.
4. Write this evaluation statement: Goal met, lung sounds clear by third day.
Correct Answer: 1
Rationale 1: Part of the evaluating process is determining whether the nursing activities had any relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep breathing? In order to know for sure, the nurse must collect more data and not assume that this particular nursing intervention had any relation to the outcome.
Rationale 2: Telling the client that his/her lungs are clear is not evrelating intervention to outcome since no mention of the intervention is made.
Rationale 3: Documenting does not show effectiveness of the intervention.
Rationale 4: Writing an evaluation statement does not show effectiveness of the intervention.
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