The nurse recognizes that client goals or outcomes should be documente

The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear and easily understood by other members of the health care team.

Of the following, the outcome statement that best meets the established criteria is the following:
1. “Vital signs will return to within normal levels for a middle aged adult.”
2. “Nursing assistant will ambulate the client in the hallway 3 times each day.”
3. “Lungs will be clear to auscultation and respiratory rate will be 20/minute.”
4. “Output will be at least 100 mL/hour of clear yellow urine within 24 hours.”

ANSWER

ANS: 4
“Output will be at least 100 mL/hour of clear yellow urine within 24 hours.” is client-centered, singular, observable, measurable, time-limited, and realistic. “Vital signs will return to within normal levels for a middle aged adult.” is not measurable (i.e., guidelines for normal are not stat-ed), and it is not time-limited (e.g., by when?). “Nursing assistant will ambulate the client in the hallway 3 times each day.” is not client-centered. “Lungs will be clear to auscultation and respir-atory rate will be 20/minute.” is not singular and it is not time-limited.