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 A

Explanation

A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.

B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.

C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.

D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).

A. not used by anyone else but the direct care providers B. concise, legal records of all care given and responses C. owned by the patient, who has a right to see the data any time he/she wishes D. confidential information and cannot be taken to court

Correct Answer is B

Explanation

A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.

B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.

C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.

D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.

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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

When documenting events in a patient's chart, the nurse should chart:

Correct Answer is A

Explanation

Patient health care records are:

Correct Answer is B

Explanation

Select the type of assessment which is performed continuously throughout nurse-patient contact:

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

The primary source of assessment information is:

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

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?

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

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

To what does objective data refer when assessing a patient?