A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:
use a Nursing Diagnosis from a source other than NANDA-I
limit the number of interventions
select interventions which will be easy to implement
involve the patient in the process
The Correct Answer is D
A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.
B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.
C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.
D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.
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Related Questions
Correct Answer is A
Explanation
A. Confidentiality: The biggest concern is maintaining patient confidentiality due to risks of unauthorized access, hacking, and breaches of protected health information (PHI).
B. Adequate forms for documentation: Computerized charting typically has structured templates, ensuring that all necessary fields are included.
C. Incorrect information: While errors can occur, computerized charting often includes safeguards like drop-down menus, alerts, and validation checks to reduce mistakes.
D. None of the answers are correct: Confidentiality is a significant concern, making option A the best answer.
Correct Answer is ["D","E"]
Explanation
A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.
B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.
C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.
D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.
E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.
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