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Patient with edema has a problem of fluid overload
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:
- A. use a Nursing Diagnosis from a source other than NANDA-I
- B. limit the number of interventions
- C. select interventions which will be easy to implement
- D. involve the patient in the process
Correct Answer: D
Rationale: Involving the patient in the care plan (D) ensures better adherence and personalization, which is critical for effective fluid reduction. A is incorrect because NANDA-I provides standardized diagnoses for accuracy. B is incorrect as interventions should be sufficient, not arbitrarily limited. C is incorrect because interventions should be effective, not merely easy.
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Select the type of assessment which is performed continuously throughout nurse-patient contact:
- A. focused
- B. body systems
- C. subjective
- D. complete
Correct Answer: A
Rationale: Focused assessments (A) are ongoing, targeting specific issues like pain or breathing during contact. Body systems (B), subjective (C), and complete (D) assessments are not continuous.
Patient with edema has a problem of fluid overload
The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)
- A. Teaching deep breathing and relaxation techniques as needed
- B. Inserting a nasogastric tube (NG) to relieve gastric distention
- C. Placing the nurse call button within reach at all times
- D. Giving hand massages daily
- E. Repositioning the patient every 2 hours to reduce pressure injury risk
- F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed
Correct Answer: A,C,D,E
Rationale: A: Teaching non-pharmacological techniques is within a nurse's scope without a physician's order. C: Ensuring the call button is accessible promotes safety independently. D: Hand massages are a comfort measure nurses can provide independently. E: Repositioning prevents pressure injuries and is an independent action. B requires a physician's order, and F involves medication administration, which is dependent.
Which of the following statements is correct about abbreviations?
- A. Every facility should have an approved abbreviations list.
- B. Creating abbreviations saves time for the person reading the chart.
- C. Writing out questionable abbreviations could make a jury think you're hiding something
- D. Abbreviating drug name and dosages helps reduce medication errors.
Correct Answer: A
Rationale: Approved abbreviation lists (A) ensure clarity and prevent errors. B, C, and D are incorrect as unapproved abbreviations cause confusion and risks.
Which of the following is an example of good charting?
- A. No complaints of pain or discomfort.'
- B. The patient states, 'It feels like a knife stabbing me.'
- C. Lump diminished.'
- D. Patient's condition much better today than yesterday.'
Correct Answer: B
Rationale: Quoting the patient's exact words (B) is precise and clear. A lacks verification, C is vague, and D lacks measurable detail.
Select the proper order of the phases of the Nursing Process:
- A. Evaluation, planning, assessment, implementation
- B. Assessment, planning, implementation, evaluation
- C. Implementation, assessment, planning, evaluation
- D. Planning, evaluation, assessment, implementation
Correct Answer: B
Rationale: The nursing process follows a logical sequence: Assessment (data collection), Planning (developing goals and interventions), Implementation (executing the plan), and Evaluation (assessing effectiveness). Only option B lists this correct order.