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. Oxygen will be continued: Continuing oxygen therapy is an intervention, not a measurable outcome.

B. The patient's coughing frequency will increase: While coughing can help clear secretions, increased coughing does not necessarily indicate improved airway clearance.

C. Cyanosis may be present: Cyanosis is a sign of worsening oxygenation, not an improved outcome.

D. Within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea: A desired outcome should be specific, measurable, and indicate improvement. The resolution of dyspnea demonstrates effective airway clearance.

A. focused B. body systems C. subjective D. complete

Correct Answer is A

Explanation

A. Focused: A focused assessment is ongoing and directed at specific problems based on the patient’s condition (e.g., assessing pain, circulation, or respiratory status frequently).

B. Body systems: Body systems assessments are structured assessments that evaluate a particular system (e.g., cardiovascular, respiratory) rather than continuous monitoring.

C. Subjective: Subjective assessment includes patient-reported symptoms but does not define the type of continuous assessment nurses perform.

D. Complete: A complete (or comprehensive) assessment is done at admission, not continuously.

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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

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

Correct Answer is D

Explanation

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

Correct Answer is A

Explanation

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:

To what does objective data refer when assessing a patient?

JCAHO regulates standards of care to:

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

Which of the following is an example of good charting?

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?

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

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