In developing the nursing plan of care, which problem has the highest priority?
B. Skin Breakdown
C. Altered nutrition
D. Self care deficit
Rationale: Aspiration, or the entry of foreign substances such as food or fluids into the lungs, may cause hypoxia or respiratory distress. Therefore, this is the highest priority in establishing the client's plan of care.
2. After establishing priorities, what action should the nurse take next in developing Mrs. Rusk's plan of care?
A. Analyze data
B. Establish goals
C. Complete an assessment
D. Implement interventions
Rationale: the nurse should first complete assessment, then analyze data to identify problems, and then establish goals. After goals and expected outcomes are established, the nurse plans and implements interventions, which are then evaluated to determine if the expected outcomes and goals were accomplished
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