Answer to Question 1
Correct Answer: 3
Rationale 1: An informal nursing care plan is a strategy for action that exists in the nurse's mind.
Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the client's care.
Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury.
Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific clientneeds not addressed by the standardized plan.
Answer to Question 2
Correct Answer: 4
Rationale 1: An informal nursing care plan is a strategy for action that exists only in the nurse's mind; this does not meet the needs expressed in the item.
Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the client's care; this does not meet the needs expressed in the item.
Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs.
Rationale 4: An individualized care plan is tailored to meet a specific client need that is not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine proceduresomething that is unplanned and a rare occurrence.
A nurse adjusts the rate of a client’s IV.
A nurse prepares a client for anesthesia and surgery.
The nurse applies a pulse oximeter sensor on the client’s finger.
Valve replacement surgery.