The nurse is participating in the planning phase of the nursing process for a new admission to a long-term care facility. When formulating a plan to meet the patient's needs, the nurse will take which action(s)? (Select all that apply.)
a. Formulate nursing interventions.
b. Collect data.
c. Make a clinical judgment about the patient.
d. Set priorities.
e. Develop measurable goals.
ANS: A, D, E
Planning is the third phase of the five-step nursing process. Once the patient has been assessed and problems have been diagnosed, plans should be formulated to meet the patient's needs. Planning usually encompasses four phases: (1) priority setting, (2) development of measurable goal and outcome statements, (3) formulation of nursing interventions, and (4) formulation of anticipated therapeutic outcomes that can be used to evaluate the patient's status. Collecting data is part of the assessment phase of the nursing process. Making a clinical judgment about the patient takes place during the diagnosis phase.
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