The nurse is evaluating the plan of care and notes that none of ...

[Chloeellawright]

The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action by the nurse is the most appropriate?
 
  1. Report the lack of achievement of the goals to the healthcare provider.
  2. Review the data and modify the plan.
  3. Reformulate the nursing diagnosis to a more realistic one.
  4. Request a consult for the client to be seen by a pulmonologist.

Question 2

The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which is an appropriate source for the nurse to use?
 
  1. The client's physical assessment.
  2. The client's self-reports.
  3. The client's healthcare provider.
  4. The client's significant other.

[hollysheppard095]

Answer to Question 1

Correct Answer: 2
The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified. Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be. Reformulating the nursing diagnosis to a more realistic one is not the best course of action, as the diagnosis established came from subjective and objective data specific to that diagnosis. There are no data to support the need for additional medical consultations.

Answer to Question 2

Correct Answer: 2
Subjective data are gathered from the interview. The interview includes the health history and focused interview. Data will come from primary and secondary sources. The client is considered the primary source of subjective information. Family members and healthcare providers are examples of secondary sources of subjective information. The physical assessment will be recorded as objective data.

[Chloeellawright]

Thank you

[hollysheppard095]

Happy to help you