Author Question: The nurse has just completed wound care on her patient who has a large abdominal wound. What should ... (Read 132 times)

Jkov05 · **on:** Jul 23, 2018

The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply.

a. Assess the patient's response to the procedure
b. Teach the patient about the procedure
c. Document the procedure in the nursing progress notes
d. Ask the patient to assist in the wound care at the next scheduled dressing change

Question 2

Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I?

a. There is little research to support nursing diagnosis labels.
b. A perfect nursing diagnosis must be written for it to be useful.
c. Standardized diagnoses are not included in all states' nurse practice acts.
d. Other professions do not recognize nursing diagnoses.

otokexnaru · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A, C
After giving care, the nurse needs to assess and record the nursing activities and the patient's responses. This is the final step in the implementation process. Documentation is a mode of communication among the members of the health team, so it needs to be done soon after finishing the procedure. It provides the information the nurse needs to evaluate the patient's health status and nursing care plan. The implementation phase ends when the nurse documents the nursing actions and evolves into evaluation as the nurse documents patient responses to the interventions. Teaching the patient and asking the patient to assist in wound care as a part of that teaching do not need to be done right away.

Answer to Question 2

A
Best practice is evidence-based practice; that is, it is developed through sound, scientific research. Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is not an issue. Having standardized nursing diagnoses recognized in state practice acts or by other professions has nothing to do with the value of the NANDA-I taxonomy.