Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Acute pain

Sore throat

Sleep apnea

Heart failure

Answer and Explanation

The Correct Answer is A

A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.

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Free Nursing Study Resources

Correct Answer is B,C,D,E,F

Explanation

A. This statement is incorrect; the nurse should touch only the inside of the first glove while putting it on to maintain sterility.

B. The outer glove package should be removed by tearing it open to access the gloves inside.

C. After putting on the second glove, interlocking hands helps to ensure that the gloves remain sterile.

D. Slipping fingers underneath the second glove cuff with the gloved dominant hand helps to keep the gloves sterile while donning them.

E. Laying the glove package on a clean flat surface above the waistline prevents contamination.

F. The dominant hand should be gloved first to maintain a sterile technique, as the dominant hand is used for the procedure.

A. Explain the importance of maintaining morning hygiene practices. B. Tell the patient that daily morning baths are the "normal" routine. C. Cancel hygiene for the day and attempt again in the morning. D. Defer the bath until evening and pass on the information to the next shift.

Correct Answer is D

Explanation

A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.

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Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.)

Correct Answer is B,C,D,E,F

Explanation

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?

Correct Answer is D

Explanation

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