Choice A reason:

Reviewing the plan of care and the prescribed treatment is the first step in the nursing process for a direct care intervention. The nurse needs to know what the goals, outcomes, and interventions are for the client before performing any action. This ensures that the nurse is following the evidence-based practice and the client's preferences. Reviewing the plan of care also helps the nurse to identify any changes or updates that might be needed based on the client's current condition.

Choice B reason:

Applying sterile gloves and cleaning the wound with saline is an important intervention for a client who has a wound infection, but it is not the first step. The nurse needs to review the plan of care and the prescribed treatment before performing any procedure to ensure that it is appropriate, safe, and effective for the client. Cleaning the wound with saline is part of the implementation phase of the nursing process, which comes after assessment, diagnosis, and planning.

Choice C reason:

Teaching the client about wound care and infection prevention is another important intervention for a client who has a wound infection, but it is not the first step either. The nurse needs to review the plan of care and the prescribed treatment before providing any education to the client. Teaching the client is also part of the implementation phase of the nursing process, which comes after assessment, diagnosis, and planning.

Choice D reason:

Documenting the wound appearance and drainage is a vital component of nursing care, but it is not the first step in a direct care intervention. The nurse needs to review the plan of care and the prescribed treatment before documenting any findings or actions. Documenting the wound appearance and drainage is part of the evaluation phase of the nursing process, which comes after assessment, diagnosis, planning, and implementation.

Choice A reason:

The client's blood glucose level is within the target range. This is not an appropriate indicator of indirect care outcomes because it reflects the direct care provided by the nurse or the client to manage diabetes. Indirect care interventions are those that are performed away from or on behalf of a client, such as documentation, infection control, consultation, or coordination of care.

Choice B reason:

The client's medical record reflects accurate and timely documentation. This is an appropriate indicator of indirect care outcomes because documentation is an essential part of indirect care that ensures continuity and quality of care for the client.

Choice C reason:

The nurse adheres to infection control policies when handling glucose testing supplies. This is an appropriate indicator of indirect care outcomes because infection control is a vital aspect of indirect care that prevents the transmission of pathogens and protects the client and the health care team.

Choice D reason:

The nurse consults with a dietitian about the client's nutritional needs. This is an appropriate indicator of indirect care outcomes because consultation is a form of indirect care that involves seeking the expertise or advice of another health care professional to improve the client's care.

Choice E reason:

The client expresses satisfaction with the quality of care received. This is not an appropriate indicator of indirect care outcomes because it reflects the client's perception of the overall care provided by the nurse or the health care team, which may include both direct and indirect care interventions.

Choice A reason:

This statement by the nurse suggests a possible intervention for the client's anxiety, but it does not demonstrate the use of evidence-based practice or clinical judgment. Evidence-based practice involves using the best available research evidence, clinical expertise, and patient preferences to make decisions about care. Clinical judgment involves applying critical thinking, knowledge, skills, and experience to assess, plan, implement, and evaluate outcomes of care. The nurse should first assess the client's level of anxiety, sources of anxiety, and coping strategies before suggesting any relaxation techniques. The nurse should also consider the client's values and expectations when choosing an intervention.

Choice B reason:

This statement by the nurse is an example of false reassurance and self-disclosure, which are not appropriate or therapeutic communication techniques. The nurse should avoid saying "I know how you feel”. because it minimizes the client's feelings and assumes that the nurse's experience is similar to the client's. The nurse should also avoid sharing personal information unless it is relevant and beneficial for the client. The nurse should focus on the client's feelings and concerns rather than their own.

Choice C reason:

This statement by the nurse is another example of false reassurance, which is not helpful or evidence-based. The nurse should avoid saying "Don't worry”. or "Everything will be fine”. because it dismisses the client's feelings and implies that the client has no reason to be anxious. The nurse should also avoid giving opinions or guarantees about the outcome of the surgery, as they are not based on facts or evidence. The nurse should acknowledge the client's anxiety and provide factual information about the surgery and the care team.

Choice D reason:

This statement by the nurse demonstrates the use of evidence-based practice and clinical judgment. The nurse is using an open-ended question to elicit the client's main concerns about the surgery, which shows respect and empathy for the client's feelings. The nurse is also using clinical judgment to assess the client's level of anxiety and knowledge deficit. The nurse is planning to provide information that might help reduce the client's anxiety.

Choice A reason:

This statement does not reflect the application of knowledge, standards, and policies when performing an intervention for a client who has a urinary catheter. Emptying the catheter bag every shift and measuring the output is a routine task that does not require any special skill or knowledge. This statement also does not specify the type of catheter or the reason for its use.

Choice B reason:

This statement reflects the application of knowledge, standards, and policies when performing an intervention for a client who has a urinary catheter. Using aseptic technique when inserting or manipulating the catheter is essential to prevent catheter-associated urinary tract infections (CAUTIs), which are a common and costly complication of indwelling catheters. The nurse demonstrates knowledge of infection prevention and control principles, as well as adherence to evidence-based guidelines and local policies for catheter care.

Choice C reason:

This statement does not reflect the application of knowledge, standards, and policies when performing an intervention for a client who has a urinary catheter. Removing the catheter as soon as possible to prevent infection is a general goal, but not a specific intervention. The nurse should also consider the indications for catheter use, the type of catheter, and the client's condition and preferences before deciding to remove the catheter. The nurse should follow the appropriate protocol for discontinuing the catheter.

Choice D reason:

This statement does not reflect the application of knowledge, standards, and policies when performing an intervention for a client who has a urinary catheter. Monitoring the urine for color, clarity, odor, and sediment is a basic assessment skill that does not require any special knowledge or policy. This statement also does not indicate what actions the nurse would take based on the findings or how they would document them.

Choice A reason:

The nurse asks the client about their goals of care and end-of-life wishes. This action demonstrates the skill of considering client preferences and values because it involves respecting and responding to individual patient's care needs, preferences, and values in all clinical decisions. It also shows that the nurse acknowledges the patient's experiences, stories, and knowledge and engages the patient more in the care process. Asking the client about their goals of care and end-of-life wishes is an example of patient-centered communication, which is fundamental to ensuring optimal health outcomes.

Choice B reason:

The nurse provides palliative care and pain management for the client. This action does not necessarily demonstrate the skill of considering client preferences and values because it does not involve communicating with patients as partners or tailoring, adjusting and balancing overall care. Providing palliative care and pain management is a standard practice for clients who have terminal cancer, but it does not reflect the individualization of care that patient-centered care requires.

Choice C reason:

The nurse respects the client's cultural and spiritual beliefs and practices. This action partially demonstrates the skill of considering client preferences and values because it involves showing concern for the patient as a person and incorporating patient values and preferences in healthcare. However, respecting the client's cultural and spiritual beliefs and practices is not enough to achieve patient-centered care; the nurse also needs to involve the patient in the decision-making process and provide information and education that are relevant to the patient's needs.

Choice D reason:

The nurse involves the client's family and significant others in the care plan. This action partially demonstrates the skill of considering client preferences and values because it involves recognizing the role of family and caregivers in the patient's care. However, involving the client's family and significant others in the care plan is not sufficient to achieve patient-centered care; the nurse also needs to ensure that the patient's voice is heard and address any potential conflicts or disagreements that may arise between the patient and their family or significant others.