A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?

Client is asleep and resting

Client had 150 mL of emesis in last hour

Ondansetron 4 mg IV bolus for nausea and vomiting

Client reports nausea and vomiting 30 minutes following surgery

Answer and Explanation

The Correct Answer is C

A.   This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B.   This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C.   It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D.   This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.

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Correct Answer is C

Explanation

A. The goal is not to avoid pressure on the stronger leg; rather, the walker is used to assist with balance and support for both legs. The client typically puts weight on both legs when using the walker, especially when moving it forward.
B. While proper hand positioning is important for stability, the specific instruction to move the walker forward 6 to 8 inches is primarily focused on facilitating safe movement and balance, rather than just ensuring hand positioning. Therefore, this is not the main purpose.
C. Moving the walker forward provides a stable base of support before the client steps forward with their weaker leg. This technique allows the client to safely shift their weight onto the walker, minimizing the risk of falls and ensuring adequate support during ambulation.
D. While maintaining the center of gravity is important for balance, the specific instruction to move the walker forward 6 to 8 inches is primarily about creating a safe distance to support the client’s weight. This action does help with balance, but it’s not the primary reason for that specific movement.

A. Uses a cane to ambulate B. Throw rugs in kitchen C. Electrical cord on floor over walkway D. Grab bar in bathroom E. Macular degeneration

Correct Answer is ["B","C","E"]

Explanation

A. While a cane can be helpful for balance, it doesn't necessarily increase fall risk. In fact, it can help reduce the risk.
B. Throw rugs can be tripping hazards, especially for individuals with visual impairments like macular degeneration.
C. Electrical cords can cause tripping and falls, especially in areas with high foot traffic.
D. A grab bar can actually help prevent falls, especially in the bathroom where there is a risk of slipping.
E. This eye condition can impair vision, making it difficult to see obstacles and potential hazards, increasing the risk of falls.

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A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the purpose of instructing the client to move the walker forward 6 to 8 inches, setting it down with all four feet on the floor when ambulating?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client. Exhibits A nurse in a provider's office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A nurse is contributing to the plan of care for clients who have rheumatoid arthritis. Which of the following plans incorporates integrative health?

A nurse is assisting with teaching a newly licensed nurse about ethical principles. Which of the following is an example of autonomy?

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?

A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

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A nurse is collecting data on a client who has peripheral neuropathy. Which of the following findings should the nurse expect?

A nurse is assisting with the care of a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?