Clinical Decision Making

The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis?

• A client’s family attending a diabetic teaching session

• Canceling physical therapy sessions on the weekend

• Normal VS and absence of wound infection in a post-op client

• A client demonstrating accurate medication administration following teaching.

After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion.

• 3, 4, 2, 1

• 4, 3, 2, 1

• 1, 3, 2, 4

• 3, 4, 1, 2

A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers:

• Notifying the physician

• Calling the wound care nurse

• Changing the wound care treatment

• Consulting with another nurse

As goals, outcomes, and interventions are developed, the nurse must:

• Be in charge of all care and planning for the client

• Be aware of and committed to accepted standards of practice from nursing and other disciples.

• Not change the plan of care for the client

• Be in control of all interventions for the client.

Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:

• Plan is developed for nursing care

• Physical assessment begins

• List of priorities is determined

• Review of the assessment is conducted with other team members.

After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal:

• Encourage client to implement guided imagery when pain begins.

• Determine effect of pain intensity on client function.

• Administer analgesic 30 minutes before physical therapy treatment.

• Pain intensity reported as a 3 or less during hospital stay

Collaborative interventions are therapies that require:

• Physician and nurse interventions

• Nurse and client interventions

• Client and Physician intervention

• Multiple health care professionals

To initiate an intervention the nurse must be competent in three areas, which include:

• Knowledge, function, and specific skills

• Experience, advanced education, and skills

• Skills, finances, and leadership.

• Leadership, autonomy, and skills.

The nursing care plan is:

• A written guideline for implementation and evaluation

• A documentation of client care.

• A projection of potential alterations in client behaviors

• A tool to set goals and project outcomes.

The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an):

• Nursing diagnosis

• Short-term goal

• Long-term goal

• Expected outcome