Level: Clinical
Difficulty: Medium
Subtopic: Skin integrity
NCLEX: After nursing care for nursing care related to skin integrity, the nurse evaluates the client response. Which act…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
After nursing care for nursing care related to skin integrity, the nurse evaluates the client response. Which action best demonstrates evaluation?
Question
A. Assume the intervention worked unless the client complains.
B. Schedule reassessment next shift without checking current status.
C. Change the plan before determining whether the finding improved.
D. Reassess the targeted finding, compare it with the expected outcome, and revise the plan if goals are not met.
B. Schedule reassessment next shift without checking current status.
C. Change the plan before determining whether the finding improved.
D. Reassess the targeted finding, compare it with the expected outcome, and revise the plan if goals are not met.
Rationale
Correct answer: D. Reassess the targeted finding, compare it with the expected outcome, and revise the plan if goals are not met.
Rationale: Evaluation compares current findings with expected outcomes and guides whether the plan continues or changes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Evaluation compares current findings with expected outcomes and guides whether the plan continues or changes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.