A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Patient will increase activity level this shift.

Patient will turn side to back to side with assistance every 2 hours.

Patient will use the walker correctly to ambulate to the bathroom as needed.

Patient will use a sliding board correctly to transfer to the bedside commode as needed.

Answer and Explanation

The Correct Answer is B

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

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Correct Answer is B

Explanation

A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.

A. Notify the health care provider about the patient's desire to donate organs. B. Contact the United Network for Organ Sharing after talking with the patient. C. Instruct the patient to talk with parents about the desire to donate organs. D. Prepare the organ donation form for the patient to sign while still oriented.

Correct Answer is C

Explanation

A. Notifying the health care provider is not the most appropriate first action, as parental consent is needed.
B. Contacting the United Network for Organ Sharing is premature without consent from the parents.
C. Since the patient is a minor, parental consent is generally required for organ donation. Instructing the patient to discuss this desire with their parents is essential for obtaining legal consent.
D. Preparing the organ donation form is also premature, as minors cannot legally consent without parental approval.

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A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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