A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Patient will increase activity level this shift.

Patient will turn side to back to side with assistance every 2 hours.

Patient will use the walker correctly to ambulate to the bathroom as needed.

Patient will use a sliding board correctly to transfer to the bedside commode as needed.

Answer and Explanation

The Correct Answer is B

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

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Correct Answer is B

Explanation

A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.

A. Explain the importance of maintaining morning hygiene practices. B. Tell the patient that daily morning baths are the "normal" routine. C. Cancel hygiene for the day and attempt again in the morning. D. Defer the bath until evening and pass on the information to the next shift.

Correct Answer is D

Explanation

A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.

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A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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