A nurse receives a patient who has been in the intensive care unit for three weeks after a motor vehicle accident. The nurse assesses the patient who reports fatigue. The nurse notes increased heart rate and decreased blood pressure when the patient moves from lying to sitting. When developing the plan of care. what problem label should the nurse use?

Risk for alteration in skin integrity

Activity Intolerance

Risk for Infection

Deficient Fluid volume

Answer and Explanation

The Correct Answer is B

A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.

B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.

C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.

D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.

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Correct Answer is B

Explanation

A. Planning. This is incorrect because the planning phase involves setting goals and determining interventions based on the assessment data. Allergy information should be collected before this phase.

B. Assessment. This is correct because the assessment phase involves gathering subjective and objective data about the patient. Asking about allergies is part of the initial health history to ensure safe care planning.

C. Implementation. This is incorrect because the implementation phase involves carrying out interventions based on the data collected in the assessment. Checking allergies before giving medications or treatments should occur earlier.

D. Evaluation. This is incorrect because evaluation involves determining the effectiveness of interventions. Allergy assessment should be completed long before this phase to prevent potential reactions.

A. Assisting a client with activities of daily living B. Administering intravenous fluids C. Collaborating with the interprofessional healthcare team D. Assessing client's pain level E. Administering medication as prescribed by the physician

Correct Answer is ["A","D"]

Explanation

A. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs independently.

B. IV fluids require a provider’s order.

C. Collaboration is not an independent intervention.

D. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs and assess pain independently.

E. Administering prescribed medication requires an order.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

The nurse is providing care to a patient in an acute care facility. Which of the following are examples of independent nursing interventions? (Select All that Apply.)

Correct Answer is ["A","D"]

Explanation

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

When should a nurse perform an ongoing assessment during a patient's hospital stay?

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?