A Practical Nurse (PN) is planning on leaving the room of a patient with a tracheotomy. The PN ensures that the client has which of the following means of communication before leaving the room?

Select one answer

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Answer and Explanation

The Correct Answer is D

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Correct Answer is ["D"]

Explanation

Choice A reason: Needs medical intervention is not the major diﬀerence between the two diagnoses. Both diagnoses may require medical intervention, depending on the severity and cause of the vomiting and the nutritional deficiency. Medical intervention is not a criterion for distinguishing between diﬀerent types of nursing diagnoses.

Therefore, this choice is incorrect.

Choice B reason: Needs no defined nursing interventions is not the major diﬀerence between the two diagnoses. Both diagnoses need defined nursing interventions, such as monitoring, teaching, counseling, or providing ﬂuids and electrolytes. Nursing interventions are essential for addressing any nursing diagnosis, whether actual or potential.

Therefore, this choice is incorrect.

Choice C reason: Will not need to be evaluated is not the major diﬀerence between the two diagnoses. Both diagnoses need to be evaluated, which involves measuring the outcomes and determining whether the interventions were eﬀective in resolving or preventing the problem. Evaluation is a vital step of the nursing process for any nursing diagnosis, whether actual or potential. Therefore, this choice is incorrect.

Choice D reason: Reﬂects a problem that does not yet exist is the major diﬀerence between the two diagnoses. Diagnosis #1 is an actual nursing diagnosis, which reﬂects a problem that exists at the present time and has signs and symptoms that can be observed or measured. Diagnosis #2 is a risk for nursing diagnosis, which reﬂects a problem that does not exist at the present time but may develop in the future if preventive measures are not taken.

Therefore, this choice is correct.

A. Identify outcomes B. Planning C. A “risk for” nursing diagnosis D. Implementation

Correct Answer is ["A"]

Explanation

Choice A reason: Identify outcomes is a step of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. Therefore, this choice is correct.

Choice B reason: Planning is a step of the nursing process that involves designing a plan of care that outlines the interventions and activities that will help the client achieve the desired outcomes. The plan of care is also developed in collaboration with the client and the nurse, and it reﬂects the client’s priorities and resources. Therefore, this choice is correct.

Choice C reason: A “risk for” nursing diagnosis is a type of nursing diagnosis that identifies a potential problem or complication that the client may develop if preventive measures are not taken. It is not a step of the nursing process,

but rather a component of the assessment step, which involves collecting and analyzing data about the client’s health status. Therefore, this choice is incorrect.

Choice D reason: Implementation is a step of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. It is not a step where the goals are developed, but rather where they are executed. Therefore, this choice is incorrect.

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A Practical Nurse (PN) is planning on leaving the room of a patient with a tracheotomy. The PN ensures that the client has which of the following means of communication before leaving the room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The Practical Nurse (PN) uses the “risk for” nursing diagnoses as identified from the: Select all that apply

Correct Answer is ["D"]

Explanation

In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

Correct Answer is ["A"]

Explanation

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

The client does not speak English; therefore, the Practical Nurse (PN) cannot use words to provide comfort during a painful procedure. The PN selects another intervention to provide comfort, which is: * Select one answer

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

During the planning step of the nursing process, the nurse performs which activity? Select one answer

Family members awaiting the outcome of a suicide atempt are tearful. Which response by the Practical Nurse (PN) is therapeutic to the family at this time? * Select one answer

The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?