NR-226 Patient Care Fundamentals - Set 1 - Part 3

Correct Answer: The client will expectorate secretions three times by evening.

An expected outcome names what the client will do, and it must be observable and timed. Expectorating secretions a stated number of times by evening describes client behaviour that the nurse can measure at evaluation. Option a is incorrect because it names a nursing action rather than a client response. Teaching coughing and deep breathing is an independent intervention and belongs in the intervention column of the plan. Option b is incorrect because encouraging fluids describes something the nurse does, so nothing about the client can be judged met or unmet later. The outcome would have to state the volume the client drinks. Option c is incorrect because monitoring is surveillance performed by the nurse, not a change in the client's condition. Compared with the correct option, it lacks both a client subject and a stated deadline.

Correct Answer: The pain rating of seven

The rating came out of the client's mouth, so it stays subjective even though it is written as a number. Only the person experiencing pain can report its intensity, which is what makes it a symptom. Option a is incorrect because guarding is a protective posture the nurse watched during repositioning. Behavior that accompanies pain is classified by how it was obtained, and this was seen rather than reported. Option c is incorrect because a pulse is measured with the nurse's fingers or a monitor. Any second nurse would count the same rate without the client saying a word, which is the test for objective data. Option d is incorrect because vomiting is an event with a visible product that can be seen, described and measured. Nausea would have been the subjective half of that pair, but emesis is a sign.

Correct Answer: Assisting the ambulatory client to the shower

Assisting a stable, ambulatory client with hygiene is routine, predictable work inside an assistive personnel's job description. It requires no interpretation of findings, which is the line that separates delegable tasks from nursing judgment. Option b is incorrect because initial and discharge teaching stay with the registered nurse in every setting. An assistive personnel cannot assess readiness to learn or confirm understanding through teach-back, so this task is never delegable. Option c is incorrect because the admission assessment demands recognition and interpretation of cues. Assistive personnel may collect data such as a blood pressure reading, but deciding what that reading means for the client is nursing. Option d is incorrect because judging an outcome against the written criterion is the evaluation step. Evaluation belongs to the nurse alone, since it compares collected data with an expected outcome and drives the next revision.

Correct Answer: Apply a cap and continue skin-to-skin contact

Cold stress is corrected with heat and by stopping heat loss, and skin-to-skin with a cap is an effective rewarming method for a stable term newborn. It costs seconds and needs no order. Option a is incorrect because bathing strips heat by evaporation from an infant with no thermal reserve. The bath is deferred until the temperature has been stable in the normal range, which makes this the harmful choice. Option b is incorrect because a nursing measure within the nurse's own scope will raise this temperature immediately. Calling first delays warming, and the provider will ask what has already been tried before ordering anything. Option d is incorrect because a glucose check is indicated once signs of cold stress such as jitteriness or respiratory distress appear. This infant shows none of them yet, and a heel stick does nothing to warm him.

Correct Answer: "Virologic testing is scheduled at set points over months."

Maternal antibody crosses the placenta and can persist for many months, so antibody testing cannot diagnose an infant. Diagnosis requires virologic nucleic acid testing repeated at intervals set by the guideline. Option a is incorrect because an antibody result in an exposed infant reflects the mother's antibodies, not the baby's infection status. That test is the classic distractor in perinatal HIV items and would be uninterpretable. Option c is incorrect because waiting a year would delay treatment for an infant who might already be infected. Virologic testing begins in the first weeks of life precisely so that therapy is not postponed. Option d is incorrect because prophylaxis lowers transmission risk without guaranteeing that transmission was prevented. The medication and the testing schedule are two separate parts of the plan, and skipping the testing leaves infection undetected.

Correct Answer: Arranging a physical therapy mobility consult

A collaborative intervention draws on expertise the nurse does not independently hold. Physical therapy contributes a safe mobility progression suited to this client, and in most facilities the referral also requires a provider order alongside nursing judgment. Option a is incorrect because encouraging fluids is a nurse-initiated action requiring no prescription and no second profession. Systemic hydration thins secretions, and the nurse decides to promote it on her own clinical judgment. Option b is incorrect because a prescribed antibiotic makes this a dependent intervention. Only one discipline is involved, and the nurse cannot start the drug without an order, which is the mark of dependence rather than collaboration. Option c is incorrect because client education belongs to the independent category in every fundamentals text. Splinted coughing is taught by the nurse alone, so no other discipline enters the picture and no prescription is needed.

Correct Answer: Recognize that expertise does not transfer across specialties

Benner's stages are tied to a specific clinical domain rather than to years licensed. An expert intensive care nurse entering labor and delivery functions as an advanced beginner there and needs support and graded assignments. Option a is incorrect because handing the hardest obstetric clients to someone without obstetric pattern recognition creates a safety problem. Skill in one domain does not supply the aspects that matter in another. Option b is incorrect because expert practice depends on a library of similar situations built inside one specialty. This nurse has that library for critical care and is starting a new one on the obstetric unit. Option d is incorrect because years on a license measure time, not competence in the area now being staffed. Benner tied progression to experience with the situations of one domain, which the transfer has reset.

Correct Answer: The outcome sets no measure or deadline

Better and soon cannot be checked off. A usable outcome states a specific client behavior, a value that can be observed, and a time by which it must occur, which this one lacks. Option a is incorrect because the statement is written about the client, not the nurse. Its fault lies in vagueness rather than in whose behavior it describes, and rewording the subject would fix nothing. Option b is incorrect because encouraging movement is a nurse-initiated action requiring no prescription. Independent interventions such as repositioning, education, and assisting with activities of daily living belong to the nurse's own scope. Option c is incorrect because defining characteristics belong to the diagnosis statement, and the item under review here is the outcome. Even a diagnosis with perfect defining characteristics cannot rescue a target no one can measure.

Correct Answer: Attainable, because the target exceeds current tolerance

Attainable asks whether this client can actually reach the target. A client who becomes breathless after ten feet cannot cover five hundred feet unassisted within one shift, so the outcome was doomed before care began. Option b is incorrect because distance in feet is one of the cleanest measurements a plan can carry. Any nurse could count the steps and record the result, so measurability is the one criterion this outcome satisfies well. Option c is incorrect because end of shift is an accepted deadline in acute care and tells the nurse exactly when to evaluate. The problem lies in the size of the target, not in the clock attached to it. Option d is incorrect because walking a stated distance without assistance names the behaviour precisely. Specificity fails when an outcome says the client will improve or do better, and this statement does neither.

Correct Answer: Reflection in action during the episode

Reflection in action means reading the client's response while still in the situation and adjusting in real time. Noticing the partial pain relief and new nausea and changing course immediately is exactly that. Option a is incorrect because reflection on action happens afterward, when the nurse reviews the episode to extract what she learned. Tanner found it is most often triggered by an outcome that surprised the nurse. Option c is incorrect because journaling is a written tool that operationalizes after the fact reflection, usually completed once clinical is over. The nurse in this stem is still at the bedside making a change. Option d is incorrect because a concept map diagrams the links among problems, supporting data, interventions and outcomes on paper. It organizes a plan of care and does not describe thinking that occurs during an intervention.