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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.

B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.

C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.

D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.

A. pain B. skin integrity C. fluid volume D. knowledge deficit

Correct Answer is A

Explanation

A. Pain: Pain is the most immediate concern in this scenario. Managing pain is critical for comfort and preventing further complications.

B. Skin integrity: While skin integrity may be a concern (e.g., pressure ulcers if immobile), it is not the most urgent issue at admission.

C. Fluid volume: There is no mention of dehydration or blood loss. Fluid volume is not the primary concern.

D. Knowledge deficit: While patient education is important, managing pain takes priority over knowledge deficits in acute injuries.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Correct Answer is D

Explanation

Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

Correct Answer is A

Explanation

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:

When using the SOAP method of charting, S stands for subjective data which means:

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

In which step of the nursing process do nurses look at outcomes?

One benefit of computerized charting is that:

Which of the following is an example of good charting?

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

What is the major concern when using a computer for documentation?