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

Client’s problem

Care plan

Evaluation

Assessment

Answer and Explanation

Correct Answer : D

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.

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Correct Answer is A

Explanation

Choice A reason: This is incorrect because it shows that the nurse is not using a systematic and evidence-based approach to care. The nurse’s notes are a form of documentation, not a source of planning.

Choice B reason: This is correct because it shows that the nurse is using a systematic and evidence-based approach to care. The nursing diagnosis is a clinical judgment that identifies the client’s actual or potential health problems or needs and provides the basis for selecting appropriate interventions.

Choice C reason: This is incorrect because it shows that the nurse is not using a holistic and individualized approach to care. The doctor’s orders are a form of prescription, not a source of planning.

Choice D reason: This is incorrect because it shows that the nurse is confusing the outcome with the process. The care plan is a written document that outlines the goals, interventions, and evaluation of care, not a source of planning.

A. Provide the client with a towel and tell the client the nurse will assist her when he/she is finished administering the tube feeding B. Stop administering the tube feeding and assist the client who spilled coﬀee with changing her wet clothing and C. assess for burns D. Request a replacement tray and assist the client with changing her wet clothing

Correct Answer is ["B"]

Explanation

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coﬀee. The nurse should not delay providing care for a client who may have suﬀered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coﬀee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coﬀee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coﬀee.

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

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Naxlex Comprehensive Predictor Exams

The basis for designing and selecting nursing interventions to meet client needs is the:

Correct Answer is A

Explanation

A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

Correct Answer is ["B"]

Explanation

When writing expected outcomes, the Practical Nurse (PN) should adhere to accepted criteria, such as which of the following? (Select all that apply)

A client with carotid stenosis has just discussed an upcoming surgery with the physician. The client tells the Practical Nurse (PN), “I wonder if I should let him cut my neck open?” Which nursing response is best?

A client with chronic renal failure is admited with a heart rate of 122 beats/minute; a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Select one answer

What should the nurse do with linens that have been soiled by a client with hepatitis?

A client of the Islamic faith refuses to eat a hot dog on his tray because he is afraid that it may contain pork products. Which of the following is the best response by the Practical Nurse (PN)?

A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client’s leg is pain free, without redness or edema. The nurse’s actions reﬂect which phase of the nursing process? Select one answer

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

A nurse is caring for a client who is hearing-impaired and takes which approach to best facilitate communication? (Select all that apply)