Answer to Question 1
C
Goals are often based on standards of care or guidelines established for minimal safe practice. Prevention of acquired infection is a standard of practice.
The statement Client will lose 4.5 kg in 90 days reflects client-specific goals.
The statement Client will walk 10 metres with minimal assistance reflects client-specific goals.
The statement Client's chronic pain will be managed with oral medication by discharge reflects client-specific goals.
Answer to Question 2
C
Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspec-tion of the colour of the skin, as stated in the outcome criterion.
Selection of appropriate wound care is an intervention, not an evaluation of a client's behaviour or response. The outcome criterion does not state anything about drainage.
Noting the colour and amount of drainage may be a part of reassessment of the client, but is not what the nurse is evaluating according to this outcome criterion.
The outcome criterion states the erythema, not the size of the ulceration, will be reduced. During the evaluation step of the nursing process, the client's behaviour or response should be compared to the outcome criterion and judged for the degree of agreement between the two.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
Common sites of amputation. (A) Upper extremities. (B) Lower extremities. The surgeon determines th
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