NCLEX Planning Nursing Care Practice Exam

NCLEX Planning Nursing Care Practice Exam

 

Which is the most important component of the nursing care plan?

A) Patient’s history

B) Patient’s needs and goals

C) Medical diagnosis

D) Nursing interventions

 

When writing a goal for a nursing care plan, the nurse should ensure that the goal is:

A) Short-term and easily achievable

B) Long-term and challenging

C) Specific, measurable, achievable, relevant, and time-bound (SMART)

D) General and flexible

 

Which of the following is the most important consideration when setting priorities for a patient’s care?

A) The patient’s preference

B) The severity of the patient’s condition

C) The nurse’s availability

D) The physician’s orders

 

A nurse is caring for a postoperative patient who is at risk for infection. What should the nurse prioritize in the care plan?

A) Promoting mobility

B) Preventing infection

C) Assessing nutritional status

D) Managing pain

 

The nurse plans care for a patient based on:

A) Doctor’s orders only

B) The patient’s needs and goals

C) A standard care protocol

D) The nurse’s assessment findings alone

 

A nurse uses the nursing diagnosis “Impaired physical mobility” for a patient. Which goal is appropriate for this diagnosis?

A) Patient will ambulate 10 feet without assistance by discharge.

B) Patient will express no pain during ambulation.

C) Patient will understand the importance of mobility.

D) Patient will be able to explain exercises to improve mobility.

 

The nurse has identified that a patient is at risk for falls. Which intervention is most appropriate to include in the care plan?

A) Place the call light within reach

B) Encourage the patient to walk independently

C) Restrict the patient’s mobility to the bed

D) Avoid offering fluids to reduce the need for bathroom visits

 

When developing a care plan for a patient with chronic pain, the nurse should include:

A) Nonpharmacological interventions

B) Only medication administration

C) A focus on invasive treatments

D) Strict bed rest

 

A nurse is evaluating a patient’s response to pain management. Which of the following is the best evaluation method?

A) Assessing vital signs

B) Observing facial expressions

C) Asking the patient to rate pain on a scale of 1 to 10

D) Checking the patient’s level of activity

 

The nurse is planning care for a patient with hypertension. What is the most important aspect of the care plan?

A) Providing education about lifestyle modifications

B) Administering antihypertensive medications

C) Monitoring blood pressure regularly

D) Encouraging the patient to rest

 

Which intervention is the priority for a patient who has an impaired airway?

A) Administer oxygen as ordered

B) Assist with coughing and deep breathing

C) Monitor respiratory rate and effort

D) Position the patient with the head elevated

 

In formulating a care plan for a patient with anxiety, which goal should the nurse prioritize?

A) Patient will decrease anxiety to a manageable level.

B) Patient will engage in regular exercise.

C) Patient will understand the cause of their anxiety.

D) Patient will learn relaxation techniques.

 

Which action would best help the nurse evaluate the effectiveness of the care plan for a patient with congestive heart failure?

A) Assessing the patient’s weight daily

B) Checking for edema

C) Monitoring oxygen saturation levels

D) All of the above

 

A patient is at risk for impaired skin integrity. Which of the following interventions should the nurse include in the care plan?

A) Repositioning the patient every two hours

B) Limiting oral fluid intake to reduce urinary frequency

C) Applying a heating pad to the skin to improve circulation

D) Encouraging the patient to remain in bed to avoid falls

 

What is the priority intervention when caring for a patient who is confused and disoriented?

A) Provide a calm and quiet environment

B) Administer sedatives as prescribed

C) Provide frequent orientation cues

D) Limit family visits to reduce stimulation

 

A nurse is caring for a patient with a history of stroke who is unable to communicate verbally. What is the priority nursing intervention?

A) Provide a communication board

B) Encourage the use of a writing pad

C) Use simple, yes-or-no questions

D) Increase the use of gestures and non-verbal cues

 

A nurse is planning care for a patient with chronic obstructive pulmonary disease (COPD). Which of the following interventions should be included?

A) Encourage the patient to quit smoking

B) Restrict the patient’s fluid intake

C) Encourage the patient to exercise vigorously

D) Administer high-flow oxygen as needed

 

When creating a care plan for a patient with diabetes mellitus, which priority nursing diagnosis should be addressed first?

A) Risk for infection

B) Imbalanced nutrition: More than body requirements

C) Ineffective health maintenance

D) Risk for impaired skin integrity

 

Which statement by the nurse is most appropriate when planning care for a patient with a terminal illness?

A) “We will focus on curative treatments.”

B) “Comfort and quality of life are our priority.”

C) “We should prepare for immediate recovery.”

D) “We will monitor lab results closely to guide interventions.”

 

A patient has a nursing diagnosis of Acute Pain related to surgical incision. What is an appropriate short-term goal for this patient?

A) Patient will ambulate 10 feet by the end of the day.

B) Patient will report pain of 4 or less on a 0–10 scale within 2 hours.

C) Patient will have no signs of infection postoperatively.

D) Patient will verbalize an understanding of pain management techniques.

 

Which of the following is the most effective method to evaluate the success of a nursing intervention for a patient with anxiety?

A) Checking vital signs

B) Observing the patient’s behavior and responses

C) Asking the family members to assess the patient’s progress

D) Administering sedatives as prescribed

 

Which of the following interventions should the nurse include in the care plan for a patient with a respiratory infection?

A) Provide frequent position changes to prevent atelectasis

B) Encourage the patient to increase physical activity

C) Administer broad-spectrum antibiotics

D) Restrict fluid intake to avoid fluid overload

 

A nurse is caring for a postoperative patient. What is the first priority when planning care for this patient?

A) Prevent infection

B) Control pain

C) Monitor for complications

D) Promote mobility

 

Which of the following is the primary goal when caring for a patient with a fractured leg?

A) Prevent infection

B) Promote mobility

C) Encourage independence

D) Ensure comfort and pain relief

 

Which of the following is a priority intervention for a patient with a nursing diagnosis of Deficient Fluid Volume?

A) Increase oral intake of fluids

B) Administer intravenous fluids as prescribed

C) Encourage high-sodium foods

D) Limit fluid intake to prevent fluid overload

 

What is the most appropriate intervention for a patient experiencing difficulty breathing?

A) Position the patient in an upright position

B) Encourage the patient to lie flat

C) Administer pain medications as prescribed

D) Reassure the patient that difficulty breathing is common

 

Which of the following should the nurse include in a care plan for a patient with a pressure ulcer?

A) Provide frequent repositioning and pressure relief

B) Apply warm compresses to the ulcer

C) Increase the patient’s caloric intake

D) Limit the patient’s fluid intake

 

What is the primary goal for a patient with a nursing diagnosis of Risk for Injury related to impaired vision?

A) Promote independence with self-care activities

B) Ensure safety in the patient’s environment

C) Provide emotional support and counseling

D) Encourage physical activity

 

When caring for a patient with a mental health disorder, the nurse should:

A) Use a non-judgmental and empathetic approach

B) Avoid making direct eye contact with the patient

C) Speak in a harsh tone to ensure compliance

D) Disregard the patient’s feelings to maintain control

 

Which action should the nurse take to evaluate a patient’s ability to perform activities of daily living?

A) Observe the patient’s ability to dress, bathe, and eat independently

B) Ask the patient to rate their ability to perform these activities

C) Monitor vital signs and oxygen levels

D) Consult with the patient’s family for their input

 

What is the first step in developing a nursing care plan?

A) Establishing priorities

B) Assessing the patient

C) Setting goals

D) Evaluating the care plan

 

Which of the following is an appropriate short-term goal for a patient with a fever?

A) Patient will maintain normal body temperature within 24 hours.

B) Patient will verbalize understanding of the infection.

C) Patient will be free from fever for the next week.

D) Patient will experience no discomfort during temperature fluctuations.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Airway Clearance.” Which intervention should be prioritized?

A) Encourage the patient to cough and deep breathe.

B) Increase the patient’s fluid intake.

C) Administer a sedative to calm the patient.

D) Place the patient in a prone position.

 

Which of the following is a correct intervention for a patient with the diagnosis of “Risk for Aspiration”?

A) Encourage the patient to eat while lying down.

B) Keep the head of the bed elevated at least 30 degrees.

C) Administer thickened liquids with every meal.

D) Encourage the patient to swallow rapidly.

 

A nurse is planning care for a patient who is at risk for dehydration. What intervention should be included?

A) Monitor the patient’s intake and output.

B) Limit fluid intake to prevent overhydration.

C) Restrict the patient’s sodium intake.

D) Offer the patient fluids only at mealtime.

 

When planning care for a patient recovering from surgery, the nurse should prioritize which of the following?

A) Preventing postoperative complications

B) Encouraging the patient to ambulate immediately

C) Limiting fluid intake to avoid fluid overload

D) Administering medications as scheduled

 

Which action is the nurse’s priority when caring for a patient in acute respiratory distress?

A) Administer oxygen as prescribed.

B) Administer pain relief.

C) Reassure the patient verbally.

D) Monitor the patient’s vital signs.

 

Which goal would be most appropriate for a patient with the nursing diagnosis of “Impaired Skin Integrity”?

A) The patient will demonstrate proper wound care by the end of the shift.

B) The patient will be free from infection within 24 hours.

C) The patient will have healed skin by discharge.

D) The patient will verbalize understanding of skin protection measures by the end of the day.

 

What intervention is most appropriate for a patient with the nursing diagnosis of “Risk for Infection”?

A) Wash hands before and after providing care.

B) Limit the patient’s physical activity.

C) Encourage a high-protein diet.

D) Provide warm compresses to the affected area.

 

A nurse is developing a care plan for a patient with a nursing diagnosis of “Acute Pain” related to surgical incision. What is the most appropriate intervention?

A) Administer pain medication as prescribed.

B) Limit the patient’s movement to avoid pain.

C) Apply ice packs to the surgical site.

D) Encourage the patient to endure the pain to build tolerance.

 

A nurse is planning care for a patient with heart failure. Which goal should the nurse prioritize?

A) The patient will demonstrate an understanding of fluid restrictions.

B) The patient will experience no episodes of shortness of breath.

C) The patient will be free from edema by discharge.

D) The patient will maintain adequate oxygen saturation.

 

Which intervention should the nurse include in the care plan for a patient with the nursing diagnosis of “Risk for Impaired Skin Integrity” related to immobility?

A) Reposition the patient every 2 hours.

B) Encourage the patient to remain in one position for extended periods.

C) Apply moisturizing cream to the patient’s skin.

D) Limit oral fluid intake to reduce skin moisture.

 

A nurse is planning care for a patient with a nursing diagnosis of “Impaired Physical Mobility.” Which goal is most appropriate for this patient?

A) The patient will ambulate with assistance within 48 hours.

B) The patient will express no discomfort during movement.

C) The patient will demonstrate an understanding of mobility exercises.

D) The patient will be able to climb stairs independently.

 

Which nursing intervention is most appropriate for a patient with the nursing diagnosis of “Imbalanced Nutrition: Less Than Body Requirements”?

A) Encourage the patient to eat three large meals a day.

B) Provide high-calorie, nutrient-dense foods.

C) Restrict fluid intake to improve appetite.

D) Offer frequent, small meals and snacks.

 

Which of the following is the priority action for a nurse caring for a patient with an indwelling urinary catheter who has a fever?

A) Take a urine specimen for culture and sensitivity.

B) Provide antipyretics as ordered.

C) Change the catheter as soon as possible.

D) Increase fluid intake to promote diuresis.

 

When caring for a patient with a nursing diagnosis of “Deficient Knowledge” about diabetes management, which intervention is most appropriate?

A) Provide written materials about diabetes management.

B) Educate the patient about the signs and symptoms of hypoglycemia.

C) Restrict the patient’s fluid intake to avoid complications.

D) Limit the patient’s physical activity to prevent hypoglycemia.

 

A nurse is caring for a patient with a nursing diagnosis of “Risk for Bleeding.” Which intervention should the nurse include in the care plan?

A) Encourage the patient to consume foods rich in vitamin K.

B) Monitor the patient for signs of bleeding.

C) Restrict the patient’s activity to reduce the risk of injury.

D) Administer anticoagulant medications as ordered.

 

Which of the following is a priority nursing intervention for a patient with a nursing diagnosis of “Ineffective Tissue Perfusion” related to decreased cardiac output?

A) Administer oxygen as ordered.

B) Limit the patient’s physical activity.

C) Maintain strict bed rest.

D) Provide a high-sodium diet to increase blood volume.

 

Which goal is most appropriate for a patient with the nursing diagnosis of “Disturbed Sleep Pattern” related to pain?

A) The patient will experience no pain during sleep.

B) The patient will report improved sleep quality within 2 nights.

C) The patient will ambulate to the bathroom independently.

D) The patient will be free from pain within 24 hours.

 

A nurse is planning care for a patient with a nursing diagnosis of “Risk for Falls.” Which intervention should the nurse prioritize?

A) Provide a walker to the patient.

B) Restrict the patient’s activity to the bed.

C) Keep the patient’s room well-lit and free from hazards.

D) Administer sedatives to help the patient sleep.

 

Which of the following interventions is most appropriate for a patient who is at risk for impaired skin integrity?

A) Turn and reposition the patient every 4 hours.

B) Provide daily baths with hot water.

C) Use pressure-relieving devices on the patient’s bed.

D) Apply moisturizing lotion to the skin after every bath.

 

When developing a care plan for a patient with a diagnosis of “Impaired Urinary Elimination,” which goal is most appropriate?

A) The patient will have a normal urinary output within 24 hours.

B) The patient will verbalize an understanding of dietary modifications.

C) The patient will demonstrate proper use of a catheter.

D) The patient will maintain a fluid balance within normal limits.

 

A nurse is planning care for a patient with a nursing diagnosis of “Acute Confusion.” What is the priority nursing intervention?

A) Encourage the patient to express feelings.

B) Provide a calm and structured environment.

C) Reassure the patient frequently.

D) Use restraints to prevent injury.

 

What is the most appropriate goal for a patient with a nursing diagnosis of “Ineffective Breathing Pattern”?

A) The patient will have a respiratory rate within normal limits within 24 hours.

B) The patient will demonstrate the ability to manage symptoms independently.

C) The patient will maintain an oxygen saturation level of 90% or higher.

D) The patient will report improved comfort and breathing ease.

 

When planning care for a patient with the diagnosis of “Impaired Gas Exchange,” which intervention is most appropriate?

A) Increase oxygen therapy as needed.

B) Place the patient in a side-lying position.

C) Administer bronchodilators as prescribed.

D) Restrict fluids to prevent overload.

 

The nurse is caring for a patient with a nursing diagnosis of “Anxiety.” What intervention is most likely to reduce anxiety?

A) Use relaxation techniques such as deep breathing.

B) Encourage the patient to remain in a quiet environment.

C) Explain procedures and the rationale behind them.

D) Limit visitors and distractions.

 

Which goal is most appropriate for a patient diagnosed with “Chronic Pain”?

A) The patient will report pain as 0/10 within 24 hours.

B) The patient will demonstrate an understanding of pain management techniques.

C) The patient will be pain-free by the end of the shift.

D) The patient will remain sedentary to avoid exacerbating pain.

 

A nurse is caring for a patient with a nursing diagnosis of “Ineffective Coping.” Which of the following interventions is most appropriate?

A) Teach the patient relaxation techniques.

B) Encourage the patient to avoid discussing stressors.

C) Provide medications to reduce stress.

D) Restrict the patient’s activities to prevent further stress.

 

Which nursing intervention is most appropriate for a patient with a diagnosis of “Constipation”?

A) Encourage the patient to drink caffeinated beverages.

B) Administer a stool softener as prescribed.

C) Limit the patient’s intake of fiber-rich foods.

D) Encourage the patient to lie in bed until symptoms resolve.

 

Which of the following is a priority action when caring for a patient with acute chest pain?

A) Administer nitroglycerin as ordered.

B) Reassure the patient verbally.

C) Encourage the patient to walk around the room.

D) Obtain a baseline set of vital signs.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Impaired Skin Integrity.” Which intervention is most appropriate?

A) Reposition the patient every 4 hours.

B) Use a pressure-relieving mattress.

C) Apply lotion to the patient’s skin daily.

D) Encourage the patient to remain in bed as much as possible.

 

A nurse is planning care for a patient who is recovering from a stroke. Which of the following should be included in the care plan?

A) Promote physical activity to improve strength.

B) Provide a low-protein diet to reduce risk of complications.

C) Encourage the patient to perform exercises for both upper and lower extremities.

D) Limit fluid intake to reduce the risk of aspiration.

 

Which of the following interventions would be appropriate for a patient with “Risk for Infection” due to a surgical wound?

A) Reassure the patient that infection is not a concern.

B) Change the wound dressing daily using sterile technique.

C) Encourage the patient to take antibiotics only when symptoms are present.

D) Restrict the patient from eating fresh fruits and vegetables.

 

A nurse is caring for a patient with a nursing diagnosis of “Deficient Knowledge” related to medication administration. Which intervention would be most appropriate?

A) Teach the patient about the purpose and side effects of medications.

B) Administer the medications and provide no further education.

C) Encourage the patient to avoid taking medications as prescribed.

D) Encourage the patient to visit the pharmacy for further education.

 

The nurse is planning care for a patient diagnosed with “Impaired Mobility.” Which of the following goals should the nurse prioritize?

A) The patient will ambulate 10 feet independently by the end of the shift.

B) The patient will perform range-of-motion exercises twice daily.

C) The patient will verbalize an understanding of the importance of mobility.

D) The patient will require minimal assistance for mobility within 48 hours.

 

A nurse is developing a care plan for a patient with “Impaired Gas Exchange” related to pneumonia. Which intervention is most important?

A) Encourage the patient to deep breathe and cough every 2 hours.

B) Administer oxygen as prescribed.

C) Position the patient in a high Fowler’s position.

D) Restrict fluid intake to prevent fluid overload.

 

A nurse is planning care for a patient with a nursing diagnosis of “Acute Pain” related to a surgical incision. What is an appropriate intervention?

A) Encourage the patient to walk frequently to relieve pain.

B) Administer pain medication as prescribed.

C) Apply cold compresses to the incision site.

D) Restrict the patient’s physical activity to avoid pain.

 

Which of the following is the most important nursing intervention for a patient with a nursing diagnosis of “Risk for Falls”?

A) Keep the bed in the lowest position.

B) Apply restraints to the patient.

C) Encourage the patient to perform activities of daily living independently.

D) Use a fall prevention screening tool to assess risks.

 

A nurse is developing a care plan for a patient with “Imbalanced Nutrition: Less Than Body Requirements.” Which intervention is most appropriate?

A) Encourage the patient to take large, infrequent meals.

B) Provide high-protein, high-calorie foods and snacks.

C) Restrict the patient’s fluid intake to decrease stomach fullness.

D) Administer appetite stimulants regularly.

 

Which intervention should the nurse implement for a patient with “Risk for Injury” due to confusion?

A) Keep the patient’s environment well-lit and free of obstacles.

B) Place restraints on the patient to ensure safety.

C) Encourage the patient to rest in bed at all times.

D) Limit the patient’s activity to prevent falls.

 

What is the priority nursing intervention for a patient with “Ineffective Breathing Pattern” due to an asthma attack?

A) Administer bronchodilators as prescribed.

B) Reposition the patient to the side-lying position.

C) Encourage the patient to increase fluid intake.

D) Provide oxygen therapy if prescribed.

 

A nurse is planning care for a patient with a nursing diagnosis of “Risk for Impaired Skin Integrity” due to immobility. Which goal is most appropriate?

A) The patient will remain free from skin breakdown during hospitalization.

B) The patient will avoid repositioning for the next 24 hours.

C) The patient will perform range-of-motion exercises independently.

D) The patient will ambulate without assistance by discharge.

 

A nurse is caring for a patient with a nursing diagnosis of “Anxiety.” Which of the following interventions would be most effective?

A) Provide reassurance that everything will be fine.

B) Help the patient to identify the cause of anxiety and develop coping mechanisms.

C) Disregard the patient’s feelings to avoid fostering unnecessary worry.

D) Offer medications to calm the patient.

 

Which nursing action is most important for a patient with “Impaired Tissue Perfusion” related to peripheral vascular disease?

A) Encourage the patient to exercise their legs frequently.

B) Ensure the patient is kept in a cool environment.

C) Encourage the patient to remain on strict bed rest.

D) Provide the patient with high-protein meals.

 

The nurse is caring for a patient who is at risk for developing a blood clot. Which intervention should the nurse include in the care plan?

A) Encourage the patient to remain sedentary.

B) Administer anticoagulant medications as prescribed.

C) Apply warm compresses to the patient’s legs.

D) Restrict the patient’s fluid intake.

 

Which goal would be most appropriate for a patient with “Impaired Urinary Elimination”?

A) The patient will maintain a fluid balance within normal limits.

B) The patient will void at least 500 mL every 12 hours.

C) The patient will have a normal voiding pattern by discharge.

D) The patient will demonstrate correct use of a catheter.

 

A nurse is caring for a patient with a nursing diagnosis of “Risk for Infection.” Which intervention should be prioritized?

A) Change dressings using aseptic technique.

B) Limit the patient’s physical activity to prevent fatigue.

C) Offer nutritious snacks every 2 hours.

D) Restrict the patient’s fluid intake to avoid fluid overload.

 

Which of the following is the priority intervention for a patient with a nursing diagnosis of “Acute Pain” related to a kidney stone?

A) Administer pain medication as prescribed.

B) Encourage the patient to drink fluids to flush out the stone.

C) Apply cold compresses to the back.

D) Restrict the patient’s activity to prevent further pain.

 

A nurse is caring for a patient diagnosed with “Chronic Pain.” Which goal is most appropriate for this patient?

A) The patient will remain pain-free for the duration of hospitalization.

B) The patient will express a decrease in pain intensity to 3/10 within 48 hours.

C) The patient will tolerate all activities without pain.

D) The patient will adhere to prescribed pain management interventions.

 

Which intervention is most appropriate for a patient with “Risk for Ineffective Thermoregulation” related to fever?

A) Apply cool compresses to the patient’s forehead.

B) Keep the patient bundled in blankets.

C) Offer the patient cold drinks.

D) Administer antipyretics as prescribed.

 

A nurse is caring for a patient with a nursing diagnosis of “Deficient Fluid Volume” related to diarrhea. Which intervention is most appropriate?

A) Administer IV fluids as prescribed.

B) Encourage the patient to increase solid food intake.

C) Restrict the patient’s fluid intake.

D) Provide the patient with caffeine to increase fluid retention.

 

The nurse is planning care for a patient with a diagnosis of “Risk for Aspiration.” Which of the following interventions is most appropriate?

A) Position the patient in a semi-Fowler’s or high-Fowler’s position during meals.

B) Encourage the patient to eat while lying flat in bed to promote digestion.

C) Offer a liquid diet to prevent choking.

D) Restrict the patient’s fluid intake to prevent aspiration.

 

Which nursing intervention would be most appropriate for a patient with “Ineffective Coping” related to a chronic illness?

A) Provide a quiet environment with minimal interaction.

B) Teach stress-reducing techniques, such as deep breathing exercises.

C) Encourage the patient to ignore their feelings of distress.

D) Provide medications to reduce anxiety as prescribed.

 

The nurse is planning care for a patient with “Risk for Injury” related to confusion. Which intervention would be most effective?

A) Keep the patient in bed at all times to prevent falls.

B) Maintain the patient’s environment free of hazards and clutter.

C) Restrict the patient’s visitors to prevent distractions.

D) Provide a sedative to decrease agitation.

 

A nurse is caring for a patient with a nursing diagnosis of “Impaired Physical Mobility.” Which goal would be most appropriate?

A) The patient will be able to walk independently within 72 hours.

B) The patient will remain in bed and avoid any physical activity.

C) The patient will perform passive range-of-motion exercises independently.

D) The patient will demonstrate a willingness to exercise regularly.

 

The nurse is planning care for a patient with a nursing diagnosis of “Risk for Infection.” Which intervention is most appropriate?

A) Use strict aseptic technique when caring for the patient.

B) Encourage the patient to avoid physical activity.

C) Restrict the patient’s fluid intake to avoid fluid overload.

D) Provide the patient with a high-fat diet to boost immunity.

 

A nurse is caring for a patient with a nursing diagnosis of “Impaired Gas Exchange” related to emphysema. Which intervention is most important?

A) Administer supplemental oxygen as prescribed.

B) Encourage the patient to deep breathe every 2 hours.

C) Keep the patient in a supine position to increase lung expansion.

D) Restrict fluid intake to reduce respiratory effort.

 

A nurse is planning care for a patient with a diagnosis of “Ineffective Breathing Pattern.” Which of the following goals would be most appropriate?

A) The patient will maintain a respiratory rate within normal limits within 24 hours.

B) The patient will have an oxygen saturation of 95% or higher within 48 hours.

C) The patient will demonstrate the ability to manage breathing exercises independently.

D) The patient will report no discomfort or shortness of breath within 72 hours.

 

Which intervention is most appropriate for a patient with a nursing diagnosis of “Chronic Pain” related to osteoarthritis?

A) Administer analgesics as prescribed.

B) Encourage the patient to remain inactive to prevent pain exacerbation.

C) Limit fluid intake to decrease inflammation.

D) Advise the patient to avoid exercises that may improve mobility.

 

Which of the following interventions is most appropriate for a patient with a diagnosis of “Ineffective Tissue Perfusion”?

A) Encourage the patient to rest frequently.

B) Administer medications as prescribed to improve circulation.

C) Apply compression stockings to reduce swelling.

D) Limit the patient’s activity to prevent further stress on the cardiovascular system.

 

A nurse is caring for a patient with a nursing diagnosis of “Impaired Skin Integrity” due to a pressure ulcer. Which of the following interventions should be included in the care plan?

A) Encourage the patient to remain in one position for long periods.

B) Reposition the patient every 2 hours to relieve pressure.

C) Apply heat therapy to the affected area to increase circulation.

D) Apply a large dressing to cover the entire body.

 

A nurse is planning care for a patient with a nursing diagnosis of “Imbalanced Nutrition: Less Than Body Requirements.” Which goal is most appropriate?

A) The patient will achieve a weight gain of 1 to 2 pounds per week.

B) The patient will experience no signs of malnutrition by discharge.

C) The patient will report an improvement in appetite within 48 hours.

D) The patient will consume a high-calorie, high-protein diet by the end of the shift.

 

The nurse is caring for a patient with “Risk for Imbalanced Fluid Volume.” Which of the following interventions is most appropriate?

A) Restrict the patient’s fluid intake to prevent overload.

B) Monitor the patient’s intake and output closely.

C) Administer diuretics as prescribed.

D) Encourage the patient to avoid any physical activity.

 

A nurse is caring for a patient with a nursing diagnosis of “Anxiety.” Which intervention is most appropriate?

A) Provide explanations for all medical procedures.

B) Encourage the patient to rest and avoid any social interaction.

C) Limit communication to reduce stress for the patient.

D) Disregard the patient’s feelings to avoid reinforcing anxiety.

 

The nurse is planning care for a patient with a diagnosis of “Impaired Urinary Elimination.” Which intervention is most appropriate?

A) Encourage the patient to drink a large amount of fluids daily.

B) Provide a catheter to ensure consistent elimination.

C) Assist the patient to the bathroom or provide a bedpan as needed.

D) Limit the patient’s fluid intake to prevent incontinence.

 

Which intervention is most appropriate for a patient with a nursing diagnosis of “Risk for Deficient Fluid Volume”?

A) Encourage the patient to drink fluids at regular intervals.

B) Limit the patient’s fluid intake to reduce the risk of overload.

C) Administer IV fluids as prescribed.

D) Monitor the patient for signs of dehydration and notify the physician.

 

A nurse is caring for a patient with a nursing diagnosis of “Impaired Comfort” related to postoperative pain. Which intervention should the nurse implement?

A) Administer prescribed pain medication as needed.

B) Encourage the patient to avoid taking pain medication.

C) Restrict the patient’s movement to prevent discomfort.

D) Offer the patient warm fluids to reduce discomfort.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Tissue Perfusion” related to poor circulation. Which of the following interventions should be included in the care plan?

A) Apply heat to the affected areas.

B) Monitor the patient’s vital signs regularly.

C) Restrict movement to promote rest.

D) Encourage the patient to sit with legs elevated frequently.

 

Which of the following interventions is appropriate for a patient with “Risk for Ineffective Airway Clearance” due to a respiratory infection?

A) Administer oxygen as prescribed.

B) Encourage the patient to take deep breaths and cough frequently.

C) Provide a sedative to help the patient relax.

D) Encourage the patient to remain flat in bed to prevent complications.

 

A nurse is caring for a patient with a diagnosis of “Impaired Memory” related to aging. Which intervention is most appropriate?

A) Encourage the patient to participate in memory exercises regularly.

B) Limit the patient’s social interaction to prevent overstimulation.

C) Administer sedatives to help the patient sleep.

D) Provide frequent reminders to perform activities of daily living.

 

The nurse is planning care for a patient who is recovering from surgery. The patient is at risk for “Impaired Skin Integrity” due to immobility. Which intervention is most appropriate?

A) Reposition the patient every 4 hours.

B) Apply moisturizers to the skin daily.

C) Reposition the patient every 2 hours.

D) Encourage the patient to sit up for long periods.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Health Maintenance.” Which goal would be most appropriate?

A) The patient will verbalize understanding of the prescribed medication regimen.

B) The patient will follow the prescribed diet plan for 24 hours.

C) The patient will stop smoking within the next week.

D) The patient will adhere to the prescribed exercise program within 3 days.

 

A nurse is caring for a patient with a nursing diagnosis of “Deficient Knowledge” related to wound care. Which action is most appropriate?

A) Instruct the patient to avoid touching the wound to prevent infection.

B) Teach the patient proper wound care techniques and signs of infection.

C) Tell the patient to keep the wound covered at all times to promote healing.

D) Encourage the patient to ignore any signs of infection.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Impaired Skin Integrity” related to immobility. Which intervention is most effective?

A) Encourage the patient to remain in one position to reduce pressure.

B) Reposition the patient every 2 hours and use pressure-relieving devices.

C) Apply moisturizing lotion to the skin every shift.

D) Use an electric blanket to maintain body temperature.

 

A nurse is caring for a patient with a diagnosis of “Risk for Infection.” Which intervention is most important to include in the care plan?

A) Encourage hand hygiene before and after patient contact.

B) Monitor the patient’s vital signs every 4 hours.

C) Maintain a sterile environment for all procedures.

D) Restrict the patient’s fluid intake to reduce the risk of infection.

 

The nurse is planning care for a patient with a nursing diagnosis of “Risk for Deficient Fluid Volume” related to diarrhea. Which of the following interventions should be prioritized?

A) Administer antidiarrheal medications as prescribed.

B) Monitor the patient’s intake and output closely.

C) Encourage the patient to avoid solid foods until diarrhea resolves.

D) Limit the patient’s fluid intake to prevent overload.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Injury” related to impaired coordination. Which intervention is most appropriate?

A) Provide a quiet environment to reduce stimulation.

B) Keep the bed in the lowest position and side rails up.

C) Restrict the patient’s mobility to prevent falls.

D) Encourage the patient to walk independently without assistance.

 

A nurse is caring for a patient with a nursing diagnosis of “Impaired Physical Mobility.” Which goal is most appropriate?

A) The patient will independently perform activities of daily living (ADLs) within 2 days.

B) The patient will ambulate 100 feet with assistance within 1 week.

C) The patient will demonstrate the ability to self-administer physical therapy exercises.

D) The patient will remain in bed to reduce discomfort.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Breathing Pattern” related to pneumonia. Which intervention is most appropriate?

A) Encourage the patient to use a spirometer every 2 hours.

B) Place the patient in a supine position to aid lung expansion.

C) Administer sedatives to reduce anxiety.

D) Restrict fluid intake to reduce congestion.

 

A nurse is caring for a patient who has recently undergone surgery. The patient is at risk for “Ineffective Airway Clearance.” Which intervention should the nurse include in the care plan?

A) Encourage the patient to take slow, deep breaths and cough.

B) Restrict the patient’s fluid intake to prevent aspiration.

C) Administer pain medications as prescribed to prevent coughing.

D) Keep the patient in a flat, supine position to prevent complications.

 

The nurse is caring for a patient with a nursing diagnosis of “Deficient Knowledge” related to self-administration of insulin. Which intervention is most appropriate?

A) Instruct the patient to take insulin only if blood glucose levels are elevated.

B) Teach the patient how to use the insulin pen and administer injections.

C) Encourage the patient to avoid regular blood glucose monitoring.

D) Allow the patient to determine their own insulin dosage based on symptoms.

 

A nurse is caring for a patient with “Ineffective Tissue Perfusion.” Which of the following interventions would most likely improve tissue perfusion?

A) Elevate the patient’s feet to promote circulation.

B) Administer anticoagulants as prescribed.

C) Encourage the patient to remain in bed to prevent exertion.

D) Apply cold compresses to the affected area to reduce swelling.

 

The nurse is caring for a patient with a diagnosis of “Risk for Fluid Volume Deficit” related to excessive vomiting. Which intervention is most appropriate?

A) Encourage the patient to drink fluids that are high in sodium.

B) Monitor vital signs for signs of dehydration.

C) Administer intravenous fluids only if the patient becomes severely dehydrated.

D) Limit oral intake to clear liquids only.

 

The nurse is planning care for a patient with a nursing diagnosis of “Impaired Urinary Elimination.” Which intervention would be most appropriate?

A) Encourage the patient to use the bathroom regularly.

B) Limit fluid intake to prevent urinary urgency.

C) Provide a urinary catheter to prevent incontinence.

D) Teach the patient to perform Kegel exercises for bladder control.

 

A nurse is caring for a patient with a nursing diagnosis of “Impaired Gas Exchange” related to acute respiratory failure. Which of the following is most important?

A) Monitor oxygen saturation levels continuously.

B) Restrict fluids to prevent fluid overload.

C) Encourage the patient to remain supine to reduce stress.

D) Administer sedatives to reduce anxiety.

 

The nurse is caring for a patient with “Risk for Impaired Skin Integrity” related to immobility. Which intervention is most appropriate?

A) Reposition the patient every 4 hours.

B) Keep the patient in one position to avoid friction.

C) Reposition the patient every 2 hours and use pressure-relieving devices.

D) Apply moisturizing lotion to the skin to prevent dryness.

 

The nurse is caring for a patient with a diagnosis of “Ineffective Coping” related to chronic illness. Which intervention should the nurse implement first?

A) Encourage the patient to avoid thinking about the illness.

B) Teach the patient relaxation and stress management techniques.

C) Provide the patient with educational materials about the illness.

D) Listen to the patient’s concerns and provide emotional support.

 

A nurse is caring for a patient with a nursing diagnosis of “Ineffective Airway Clearance” related to post-surgical recovery. Which intervention is most appropriate?

A) Encourage the patient to cough and deep breathe every 2 hours.

B) Position the patient flat in bed to promote comfort.

C) Administer analgesics to relieve pain and suppress coughing.

D) Restrict oral intake to prevent aspiration.

 

The nurse is planning care for a patient with a nursing diagnosis of “Risk for Impaired Nutrition.” Which intervention should be included?

A) Restrict the patient’s intake of solid foods.

B) Provide a high-protein, high-calorie diet as tolerated.

C) Administer antidiarrheal medications as prescribed.

D) Encourage the patient to drink liquids only to prevent dehydration.

 

A nurse is caring for a patient with a diagnosis of “Impaired Physical Mobility.” Which goal would be most appropriate?

A) The patient will walk independently within 1 week.

B) The patient will ambulate with assistance within 3 days.

C) The patient will demonstrate full range-of-motion exercises within 24 hours.

D) The patient will remain in bed until pain subsides.

 

A nurse is caring for a patient with a nursing diagnosis of “Impaired Skin Integrity” related to incontinence. Which intervention is most appropriate?

A) Apply a moisture barrier cream to protect the skin.

B) Encourage the patient to drink large amounts of fluid.

C) Use a heat lamp to keep the skin dry.

D) Massage the affected area to promote circulation.

 

The nurse is planning care for a patient with a nursing diagnosis of “Risk for Impaired Gas Exchange” due to asthma. Which intervention should be included in the care plan?

A) Encourage the patient to lie flat to improve lung expansion.

B) Administer prescribed bronchodilators as ordered.

C) Restrict fluid intake to reduce mucous production.

D) Keep the patient in a supine position to promote oxygenation.

 

The nurse is caring for a patient with a nursing diagnosis of “Acute Pain” related to a fractured limb. Which intervention is most appropriate?

A) Reposition the patient every 4 hours.

B) Administer prescribed analgesics as needed.

C) Encourage the patient to ignore the pain to focus on recovery.

D) Apply cold compresses to the affected limb for 10 minutes.

 

A nurse is caring for a patient with a nursing diagnosis of “Risk for Impaired Urinary Elimination” related to a urinary tract infection (UTI). Which intervention is most appropriate?

A) Limit the patient’s fluid intake to prevent bladder distention.

B) Teach the patient proper hygiene techniques to prevent further infection.

C) Restrict the patient’s ambulation to reduce discomfort.

D) Administer antibiotics as prescribed and monitor urine output.

 

The nurse is planning care for a patient with a nursing diagnosis of “Ineffective Tissue Perfusion” related to peripheral artery disease. Which intervention is most appropriate?

A) Elevate the patient’s legs to reduce edema.

B) Apply compression stockings to improve blood circulation.

C) Encourage the patient to walk short distances as tolerated.

D) Restrict the patient’s fluid intake to prevent fluid overload.

 

A nurse is caring for a patient who is at risk for “Ineffective Airway Clearance” due to a post-operative condition. Which intervention is most important?

A) Encourage the patient to cough and deep breathe every 2 hours.

B) Administer sedatives to help the patient relax and rest.

C) Keep the patient in a flat, supine position to reduce discomfort.

D) Encourage the patient to consume fluids to avoid dehydration.

 

The nurse is caring for a patient with a nursing diagnosis of “Impaired Physical Mobility” related to a leg fracture. Which intervention should be included in the care plan?

A) Assist the patient with daily range-of-motion exercises.

B) Instruct the patient to avoid movement until the fracture heals.

C) Encourage the patient to walk without support to improve strength.

D) Keep the patient in bed for the duration of recovery.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Imbalanced Nutrition” due to anorexia. Which intervention is most appropriate?

A) Encourage the patient to eat large meals.

B) Provide small, frequent meals that are high in calories.

C) Restrict fluid intake to reduce nausea.

D) Limit protein intake to prevent gastrointestinal discomfort.

 

A nurse is caring for a patient with a nursing diagnosis of “Risk for Infection” due to open abdominal surgery. Which intervention is most appropriate?

A) Administer antibiotics as prescribed.

B) Provide the patient with a sterile dressing change every shift.

C) Encourage the patient to cough and deep breathe every 2 hours.

D) Monitor the surgical wound for signs of infection.

 

The nurse is planning care for a patient with a nursing diagnosis of “Deficient Knowledge” related to newly diagnosed diabetes. Which intervention is most appropriate?

A) Instruct the patient to avoid testing blood glucose levels.

B) Teach the patient how to administer insulin injections and monitor blood glucose levels.

C) Encourage the patient to reduce physical activity to prevent injury.

D) Restrict the patient’s diet to a low-carbohydrate regimen.

 

The nurse is caring for a patient with a nursing diagnosis of “Impaired Gas Exchange” due to pneumonia. Which intervention should the nurse include in the care plan?

A) Administer prescribed antibiotics and monitor oxygen saturation.

B) Restrict fluid intake to reduce respiratory congestion.

C) Instruct the patient to avoid deep breathing exercises.

D) Keep the patient in a flat, supine position to minimize discomfort.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Coping” related to the loss of a spouse. Which intervention is most appropriate?

A) Encourage the patient to avoid expressing grief.

B) Provide the patient with resources for counseling and support groups.

C) Advise the patient to engage in social activities to distract from the grief.

D) Restrict visitation to prevent the patient from becoming overwhelmed.

 

The nurse is caring for a patient with a nursing diagnosis of “Impaired Skin Integrity” related to pressure ulcers. Which intervention should be included in the care plan?

A) Reposition the patient every 2 hours and use pressure-relieving devices.

B) Apply petroleum jelly to the wound to promote healing.

C) Keep the wound dry and avoid dressing changes to prevent infection.

D) Encourage the patient to remain in one position to prevent skin breakdown.

 

The nurse is caring for a patient with a nursing diagnosis of “Acute Pain” related to a surgical wound. Which intervention is most appropriate?

A) Provide analgesics as prescribed and assess the pain level regularly.

B) Encourage the patient to ignore the pain and focus on recovery.

C) Apply heat to the wound to reduce discomfort.

D) Restrict the patient’s movement to prevent further pain.

 

A nurse is caring for a patient with a nursing diagnosis of “Risk for Deficient Fluid Volume” related to vomiting. Which intervention is most appropriate?

A) Monitor the patient’s vital signs for signs of dehydration.

B) Encourage the patient to drink large amounts of water.

C) Administer antiemetics as prescribed to prevent further vomiting.

D) Restrict fluids to avoid fluid overload.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Injury” related to confusion. Which intervention should the nurse include in the care plan?

A) Keep the patient’s environment free from hazards.

B) Allow the patient to move freely to maintain independence.

C) Restrict the patient’s movement to prevent injury.

D) Apply restraints to prevent falls.

 

The nurse is planning care for a patient with a nursing diagnosis of “Impaired Memory” related to age. Which intervention is most appropriate?

A) Encourage the patient to participate in memory exercises regularly.

B) Restrict the patient’s activities to prevent confusion.

C) Limit visitors to reduce distractions.

D) Discourage the patient from engaging in social interactions.

 

A nurse is caring for a patient with a nursing diagnosis of “Risk for Impaired Skin Integrity” related to the use of a cast. Which intervention is most appropriate?

A) Encourage the patient to keep the cast dry at all times.

B) Apply lotion to the cast to prevent it from becoming stiff.

C) Reposition the patient every 4 hours to relieve pressure.

D) Monitor the skin for signs of irritation or breakdown.

 

The nurse is caring for a patient with a nursing diagnosis of “Impaired Mobility” related to a hip replacement surgery. Which intervention is most appropriate?

A) Encourage the patient to rest in bed to prevent falls.

B) Assist the patient with walking and physical therapy exercises.

C) Keep the patient in a supine position at all times.

D) Limit the patient’s activity to prevent stress on the hip.

 

The nurse is planning care for a patient with a nursing diagnosis of “Risk for Deficient Knowledge” related to self-care for diabetes. Which intervention is most appropriate?

A) Provide the patient with a list of foods to avoid.

B) Teach the patient how to monitor blood glucose levels and administer insulin.

C) Encourage the patient to stop taking prescribed medications as needed.

D) Advise the patient to only eat once a day to control blood sugar.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Tissue Perfusion” related to coronary artery disease. Which intervention is most appropriate?

A) Encourage the patient to take short, frequent walks.

B) Limit fluid intake to prevent fluid retention.

C) Elevate the legs to improve circulation.

D) Administer prescribed beta-blockers as ordered.

 

The nurse is caring for a patient with a nursing diagnosis of “Impaired Urinary Elimination” related to bladder retention. Which intervention is most appropriate?

A) Encourage the patient to limit fluid intake to avoid urgency.

B) Instruct the patient to perform regular bladder emptying.

C) Apply a heat compress to the lower abdomen to increase bladder tone.

D) Restrict the patient’s intake of caffeinated beverages.

 

A nurse is planning care for a patient with a nursing diagnosis of “Ineffective Breathing Pattern” related to chronic obstructive pulmonary disease (COPD). Which intervention is most appropriate?

A) Administer prescribed bronchodilators as needed.

B) Place the patient in a prone position to encourage lung expansion.

C) Encourage the patient to restrict physical activity to conserve energy.

D) Monitor vital signs every 4 hours.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Injury” related to dizziness from medication side effects. Which intervention should be included in the care plan?

A) Encourage the patient to change positions quickly to increase circulation.

B) Ensure that the patient has a clear path to the bathroom and is assisted with ambulation.

C) Restrict the patient from ambulating to prevent falls.

D) Instruct the patient to avoid using assistive devices like walkers or canes.

 

A nurse is planning care for a patient with a nursing diagnosis of “Risk for Imbalanced Nutrition” related to chemotherapy. Which intervention is most appropriate?

A) Encourage the patient to consume large meals with high fiber.

B) Offer frequent, small meals that are high in protein and calories.

C) Advise the patient to avoid fluids with meals to prevent nausea.

D) Limit salt intake to avoid fluid retention.

 

The nurse is caring for a patient with a nursing diagnosis of “Impaired Skin Integrity” due to a surgical wound. Which intervention should be included in the care plan?

A) Apply a heat compress to the wound to increase blood flow.

B) Keep the wound dry and intact and change the dressing as needed.

C) Massage the wound site to promote circulation and healing.

D) Instruct the patient to avoid all activity until the wound heals completely.

 

A nurse is caring for a patient with a nursing diagnosis of “Ineffective Health Maintenance” related to chronic alcohol use. Which intervention is most appropriate?

A) Teach the patient how to manage withdrawal symptoms independently.

B) Encourage the patient to attend Alcoholics Anonymous meetings.

C) Discourage the patient from seeking support from loved ones.

D) Restrict the patient’s social interactions to prevent temptation.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Coping” related to family stress. Which intervention is most appropriate?

A) Encourage the patient to discuss feelings openly with family members.

B) Advise the patient to avoid confronting family members about issues.

C) Provide the patient with educational materials on coping strategies.

D) Suggest that the patient avoid social interactions to minimize stress.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Impaired Skin Integrity” related to immobility. Which intervention should the nurse include in the care plan?

A) Encourage the patient to stay in one position to prevent pressure.

B) Reposition the patient every 2 hours and provide pressure-relieving devices.

C) Apply petroleum jelly to the skin to prevent breakdown.

D) Keep the patient in a sitting position to prevent fluid accumulation.

 

A nurse is planning care for a patient with a nursing diagnosis of “Acute Pain” related to a recent surgery. Which intervention is most appropriate?

A) Encourage the patient to rest and avoid any movement to prevent pain.

B) Administer analgesics as prescribed and assess pain levels regularly.

C) Apply heat to the surgical site to alleviate discomfort.

D) Encourage the patient to take deep breaths to distract from pain.

 

The nurse is planning care for a patient with a nursing diagnosis of “Risk for Constipation” due to immobility. Which intervention should the nurse include?

A) Encourage the patient to rest in bed to conserve energy.

B) Increase the patient’s fluid intake and encourage ambulation as tolerated.

C) Limit dietary fiber intake to prevent bloating.

D) Administer stool softeners daily without further assessment.

 

The nurse is caring for a patient with a nursing diagnosis of “Deficient Knowledge” related to new diagnosis of hypertension. Which intervention is most appropriate?

A) Instruct the patient to monitor blood pressure daily and take prescribed medications.

B) Encourage the patient to limit fluid intake to control blood pressure.

C) Advise the patient to avoid taking medications during periods of stress.

D) Recommend the patient not to engage in physical activity to prevent stress.

 

The nurse is caring for a patient with a nursing diagnosis of “Ineffective Peripheral Tissue Perfusion” related to diabetes. Which intervention is most appropriate?

A) Encourage the patient to take regular warm baths to improve circulation.

B) Monitor for signs of infection, especially in the feet and lower extremities.

C) Restrict fluid intake to prevent edema.

D) Limit the patient’s ambulation to prevent injury.

 

The nurse is caring for a patient with a nursing diagnosis of “Impaired Gas Exchange” due to pneumonia. Which intervention should be included in the care plan?

A) Administer oxygen as prescribed and monitor pulse oximetry.

B) Encourage the patient to remain in a supine position to facilitate lung expansion.

C) Administer fluids to thin secretions.

D) Restrict the patient’s physical activity to prevent fatigue.

 

The nurse is caring for a patient with a nursing diagnosis of “Risk for Infection” related to surgical incision. Which intervention is most appropriate?

A) Administer antibiotics as prescribed and monitor the surgical site for signs of infection.

B) Encourage the patient to cough and deep breathe to reduce infection risk.

C) Apply petroleum jelly to the incision site to reduce infection.

D) Avoid dressing changes to prevent contamination.

 

A nurse is planning care for a patient with a nursing diagnosis of “Risk for Impaired Skin Integrity” related to prolonged bed rest. Which intervention is most appropriate?

A) Reposition the patient every 4 hours.

B) Encourage the patient to limit fluid intake.

C) Provide pressure-relieving devices and reposition the patient every 2 hours.

D) Keep the patient in a seated position to reduce pressure.

 

The nurse is caring for a patient with a nursing diagnosis of “Deficient Knowledge” related to self-care for heart failure. Which intervention is most appropriate?

A) Educate the patient on the importance of taking prescribed medications and monitoring symptoms.

B) Advise the patient to restrict fluid intake to prevent fluid overload.

C) Encourage the patient to engage in heavy physical activity to strengthen the heart.

D) Discourage the patient from seeking support from family members.

 

Questions and Answers for Study Guide

 

Describe how the nurse should plan care for a patient with a nursing diagnosis of “Impaired Gas Exchange” related to pneumonia.

Answer:

Planning care for a patient with “Impaired Gas Exchange” related to pneumonia involves addressing the physiological and psychological needs of the patient to optimize oxygenation and minimize complications. The nurse’s primary focus should be improving respiratory function, preventing further complications, and promoting the patient’s comfort.

1. Assessment: The nurse should assess the patient’s respiratory status, including lung sounds, oxygen saturation, respiratory rate, and pattern. Additional assessment includes evaluating the patient’s level of consciousness, signs of hypoxia, and ability to expectorate secretions.
2. Interventions:
   • Oxygen Therapy: Administer supplemental oxygen to maintain oxygen saturation levels above 92%. This will help improve oxygenation and decrease respiratory distress.
   • Positioning: Position the patient in a high-Fowler’s position to facilitate lung expansion and improve gas exchange. Encouraging frequent repositioning can help prevent atelectasis.
   • Airway Clearance: Promote deep breathing and coughing exercises, or consider the use of incentive spirometry to improve lung expansion and help clear secretions.
   • Medications: Administer prescribed medications such as bronchodilators and corticosteroids to reduce inflammation and open airways, facilitating improved breathing.
   • Hydration: Encourage adequate fluid intake to thin respiratory secretions, making them easier to expectorate.
3. Evaluation: Evaluate the effectiveness of the interventions by monitoring improvements in oxygen saturation levels, respiratory rate, and lung sounds. Assess the patient’s ability to perform deep breathing exercises and expectorate secretions. If the patient shows no improvement, further interventions such as additional medications or mechanical ventilation may be required.

 

Discuss the role of the nurse in planning care for a patient with a nursing diagnosis of “Deficient Knowledge” related to newly diagnosed diabetes.

Answer:

When planning care for a patient with a nursing diagnosis of “Deficient Knowledge” related to a newly diagnosed condition like diabetes, the nurse must focus on educating the patient to enhance understanding of the disease, self-management strategies, and preventing complications.

1. Assessment: The nurse should assess the patient’s current understanding of diabetes, their willingness to learn, and the barriers to learning, such as language, cognitive ability, or emotional stress. Assessing the patient’s support system is also crucial to ensure they have access to resources that can aid in managing their condition.
2. Interventions:
   • Education on Diabetes: Provide individualized education on the nature of diabetes, the role of insulin, and how it affects blood sugar levels. Use simple language and visuals to explain complex concepts.
   • Blood Glucose Monitoring: Teach the patient how to monitor their blood glucose levels at home. Ensure they are proficient in using the glucometer and understanding target blood glucose ranges.
   • Dietary Modifications: Educate the patient about the importance of a balanced diet, carbohydrate counting, and meal planning. Emphasize the need for consistency in timing and quantity of meals to manage blood glucose levels effectively.
   • Exercise and Lifestyle: Encourage regular physical activity and explain how exercise can help control blood sugar levels. Offer suggestions for integrating exercise into daily routines.
   • Medication Management: Ensure the patient understands how and when to take their medications, whether it is insulin or oral hypoglycemics. Explain the importance of adhering to prescribed dosages and the consequences of noncompliance.
3. Evaluation: Regular follow-up assessments are essential to determine if the patient has internalized the information. The nurse should evaluate the patient’s ability to demonstrate proper blood glucose monitoring, medication administration, and lifestyle changes. Feedback should be used to reinforce education and make any necessary adjustments to the care plan.

 

Explain the nurse’s role in planning care for a patient with “Risk for Infection” related to a surgical wound.

Answer:

Planning care for a patient with a “Risk for Infection” related to a surgical wound involves preventing infection, promoting wound healing, and educating the patient on proper wound care.

1. Assessment: The nurse should assess the surgical site for signs of infection, including redness, swelling, heat, pain, and drainage. The patient’s immune status, presence of comorbidities (e.g., diabetes), and recent antibiotic use should also be considered.
2. Interventions:
   • Wound Care: Cleanse and dress the wound as per the surgeon’s orders. Use sterile technique to avoid introducing pathogens and to promote healing. Monitor for signs of infection and document findings.
   • Antibiotic Administration: Administer prescribed antibiotics as ordered and ensure the patient completes the full course to prevent the development of antibiotic resistance.
   • Hand Hygiene and Aseptic Technique: Teach the patient and their caregivers the importance of proper hand hygiene and aseptic technique when handling the surgical site or changing dressings.
   • Nutritional Support: Encourage adequate nutrition, especially protein intake, to promote wound healing and improve immune function.
   • Activity Restrictions: Advise the patient to avoid activities that could put stress on the wound site, such as heavy lifting or vigorous exercise, until healing is complete.
3. Evaluation: The nurse should monitor the surgical site regularly for any signs of infection, such as increased redness, drainage, or fever. The patient should be encouraged to report any signs of infection immediately. If there is no sign of infection, the care plan should focus on further promoting healing and preventing complications.

 

How should the nurse plan care for a patient with a nursing diagnosis of “Impaired Mobility” due to a recent stroke?

Answer:

Planning care for a patient with “Impaired Mobility” due to a stroke requires a comprehensive approach that focuses on maintaining safety, promoting rehabilitation, and preventing complications from immobility.

1. Assessment: The nurse should assess the patient’s current level of mobility, strength, and ability to perform activities of daily living (ADLs). It is important to evaluate the side effects of the stroke, such as paralysis or weakness on one side of the body, and any cognitive or communication difficulties.
2. Interventions:
   • Range of Motion (ROM) Exercises: Assist the patient with passive or active ROM exercises to maintain joint mobility and prevent contractures. Encourage the patient to actively participate in exercises if possible.
   • Physical Therapy: Collaborate with the physical therapist to develop a rehabilitation plan that will help the patient regain strength, mobility, and independence.
   • Assistive Devices: Provide the patient with assistive devices such as walkers, canes, or wheelchairs to promote mobility and independence. Ensure proper fitting and usage.
   • Safety Precautions: Implement fall prevention strategies such as ensuring the patient has a safe environment, use of non-slip footwear, and the placement of call bells within reach.
   • Positioning: Reposition the patient regularly to prevent pressure ulcers and promote circulation. Support the affected side with pillows to avoid contractures.
3. Evaluation: Regularly assess the patient’s mobility progress, noting any improvements or setbacks. Monitor for signs of complications such as deep vein thrombosis (DVT) or pressure ulcers. The nurse should provide positive reinforcement to the patient to encourage participation in rehabilitation and self-care.

 

How should the nurse plan care for a patient with “Acute Pain” related to a postoperative abdominal incision?

Answer:

Planning care for a patient with “Acute Pain” related to a postoperative abdominal incision requires assessing the pain level, providing effective pain management strategies, and promoting healing while minimizing discomfort.

1. Assessment: The nurse should assess the patient’s pain level using a standardized pain scale (e.g., 0-10 scale). Additional information about the pain’s location, intensity, duration, and triggers should be gathered. The nurse should also assess for signs of complications, such as infection or hemorrhage, which can exacerbate pain.
2. Interventions:
   • Pain Management: Administer prescribed analgesics (e.g., opioids, NSAIDs) as ordered to manage pain effectively. Consider using a multimodal approach, such as combining medications with non-pharmacological methods.
   • Non-Pharmacological Techniques: Encourage relaxation techniques, deep breathing exercises, and guided imagery to help the patient manage pain. Positioning the patient in a way that reduces strain on the incision site can also help minimize discomfort.
   • Wound Care: Ensure proper wound care to prevent complications like infection, which could intensify pain. Provide the patient with clear instructions on how to care for the incision at home.
   • Activity Promotion: Encourage early ambulation to prevent complications like deep vein thrombosis (DVT) and improve circulation, while considering the patient’s comfort and pain levels.
   • Patient Education: Educate the patient on the importance of adhering to the pain management plan and seeking assistance if pain becomes unmanageable.
3. Evaluation: The nurse should regularly reassess the patient’s pain level and evaluate the effectiveness of the interventions. Adjustments should be made based on the patient’s feedback. If pain persists despite interventions, the nurse should consult with the healthcare provider for further management options.

 

Discuss how the nurse should plan care for a patient with “Fluid Volume Deficit” due to diarrhea.

Answer:

Planning care for a patient with “Fluid Volume Deficit” due to diarrhea involves assessing the extent of dehydration, restoring fluid balance, and monitoring for complications associated with electrolyte imbalances.

1. Assessment: The nurse should assess the patient’s vital signs, including blood pressure, heart rate, and temperature, as well as signs of dehydration (e.g., dry mucous membranes, decreased urine output, and skin turgor). Monitoring laboratory results, such as serum electrolyte levels (e.g., sodium, potassium), is critical to determine the severity of fluid volume deficit.
2. Interventions:
   • Fluid Replacement: Administer oral rehydration solutions (ORS) or intravenous fluids as prescribed to restore lost fluids and electrolytes. Monitor intake and output (I&O) closely to assess the effectiveness of fluid therapy.
   • Electrolyte Management: Monitor and correct any electrolyte imbalances, especially potassium and sodium, to prevent complications such as arrhythmias or muscle weakness.
   • Dietary Adjustments: Advise the patient to avoid high-fiber and irritating foods. Once the patient’s condition improves, encourage a bland diet (e.g., BRAT diet – bananas, rice, applesauce, toast) until the gastrointestinal system stabilizes.
   • Monitoring for Complications: Watch for signs of hypovolemic shock, such as hypotension, tachycardia, and confusion. Alert the healthcare team if these symptoms occur, as they may require further interventions like blood transfusions or more aggressive fluid resuscitation.
3. Evaluation: The nurse should regularly assess the patient’s hydration status and monitor vital signs for improvements. Reevaluate the I&O balance to ensure that fluid replacement is effective. Once the patient shows signs of adequate hydration (e.g., improved urine output, stable vital signs), the nurse can begin to transition the patient to oral rehydration and maintain fluid balance with continued monitoring.

 

Explain the role of the nurse in planning care for a patient with “Risk for Impaired Skin Integrity” related to immobility.

Answer:

Planning care for a patient with “Risk for Impaired Skin Integrity” due to immobility requires proactive strategies to prevent pressure ulcers, promote skin health, and maintain overall comfort.

1. Assessment: The nurse should assess the patient’s skin regularly for signs of pressure injuries, particularly over bony prominences (e.g., heels, sacrum, elbows). The patient’s level of mobility and sensory perception should be evaluated using tools like the Braden Scale for Pressure Ulcer Risk.
2. Interventions:
   • Repositioning: Implement a regular schedule for repositioning the patient at least every two hours to relieve pressure on vulnerable areas. Use pillows or foam wedges to offload pressure from bony prominences.
   • Skin Care: Keep the skin clean and dry. Use moisture barrier creams to protect the skin from excessive moisture and incontinence. Ensure proper hygiene, especially for areas that may be in contact with bodily fluids.
   • Nutrition: Encourage adequate protein and calorie intake to support skin integrity and wound healing. Consult a dietitian to ensure the patient’s diet meets nutritional needs.
   • Support Surfaces: Utilize specialized mattresses, overlays, or cushions to reduce pressure and promote comfort. Air-fluidized beds or low-air-loss mattresses may be considered for patients at high risk.
   • Education: Teach the patient and their caregivers about the importance of repositioning, maintaining skin hygiene, and the signs of skin breakdown. Ensure they understand the need for frequent skin assessments.
3. Evaluation: The nurse should regularly assess the patient’s skin to identify early signs of pressure ulcers. Monitoring the effectiveness of repositioning and support surfaces is essential. If any pressure injuries develop, the nurse should adjust the care plan accordingly and consult with the wound care team for further management.

 

Discuss how the nurse should plan care for a patient with “Anxiety” related to the anticipation of surgery.

Answer:

Planning care for a patient with “Anxiety” related to the anticipation of surgery requires addressing both the physiological and emotional aspects of anxiety, providing comfort, and promoting relaxation.

1. Assessment: The nurse should assess the level of anxiety using a scale or by observing physical and behavioral signs, such as restlessness, tachycardia, or hyperventilation. The nurse should also explore the patient’s concerns about the surgery, ensuring that any misconceptions or fears are identified.
2. Interventions:
   • Provide Information: Offer clear, concise information about the surgery, the expected outcomes, and what to expect before, during, and after the procedure. Addressing the patient’s questions can help reduce fear of the unknown.
   • Relaxation Techniques: Teach the patient relaxation strategies such as deep breathing, guided imagery, or progressive muscle relaxation to help reduce anxiety.
   • Emotional Support: Offer emotional support by actively listening to the patient’s concerns. Reassure the patient that the healthcare team is experienced and that their safety is the priority. Allow the patient to express their feelings.
   • Preoperative Medication: If prescribed, administer preoperative anxiolytics or sedatives as ordered to help the patient relax and sleep before the surgery.
   • Involve Family: Encourage the presence of a supportive family member to provide comfort and reduce feelings of isolation.
3. Evaluation: The nurse should evaluate the patient’s anxiety level before and after the interventions. Follow-up care should be provided post-surgery to assess the patient’s emotional well-being and adjust the care plan as necessary to address any residual anxiety or stress.

 

How should the nurse plan care for a patient with “Risk for Infection” related to an indwelling urinary catheter?

Answer:

Planning care for a patient with “Risk for Infection” related to an indwelling urinary catheter requires careful monitoring, implementation of infection prevention strategies, and patient education.

1. Assessment: The nurse should assess the patient for any signs of infection such as fever, dysuria, cloudy or foul-smelling urine, or elevated white blood cell count. Monitoring urine output and the condition of the catheter insertion site is crucial.
2. Interventions:
   • Sterile Technique: Ensure that the catheter is inserted using aseptic technique and that all care, including catheterization and urine collection, is performed under sterile conditions.
   • Regular Monitoring: Perform routine assessments of the catheter and surrounding area for signs of infection. Ensure the catheter is properly secured to prevent movement and trauma at the insertion site.
   • Catheter Care: Maintain proper hygiene around the catheter insertion site. Clean the catheter with soap and water daily, and ensure the tubing is free of kinks. Keep the drainage bag below the level of the bladder to prevent backflow.
   • Adequate Hydration: Encourage adequate fluid intake to promote regular urine flow and minimize the risk of bacterial growth. Ensure the patient maintains a balanced intake of fluids based on their medical condition.
   • Discontinuation When Possible: Remove the catheter as soon as it is no longer needed to reduce the risk of infection. The nurse should assess the need for the catheter regularly and follow protocols for its timely removal.
3. Evaluation: The nurse should evaluate the patient for any signs of infection, including fever, redness or drainage around the catheter insertion site, and changes in urine characteristics. If any signs of infection develop, appropriate measures, such as sending a urine sample for culture and initiating antibiotics, should be taken.

 

Explain the role of the nurse in planning care for a patient with “Risk for Impaired Nutrition” due to anorexia.

Answer:

Planning care for a patient with “Risk for Impaired Nutrition” due to anorexia involves addressing the underlying cause of anorexia, providing nutritional support, and monitoring for complications related to malnutrition.

1. Assessment: The nurse should assess the patient’s eating habits, body weight, and any contributing factors to anorexia, such as emotional distress or a medical condition. Monitoring laboratory results such as albumin and electrolytes can help assess nutritional status and identify any deficiencies.
2. Interventions:
   • Nutritional Support: Collaborate with a dietitian to develop an individualized nutrition plan that meets the patient’s caloric and protein needs. For patients unable to consume enough food orally, consider alternatives like enteral nutrition or parenteral nutrition.
   • Encourage Small, Frequent Meals: Encourage the patient to eat small, frequent meals rather than large ones to reduce the feeling of fullness or discomfort. Offer foods that are high in calories and protein to optimize nutritional intake.
   • Promote a Comfortable Environment: Create a calm and relaxed eating environment to encourage food intake. Limit distractions and allow the patient adequate time to eat.
   • Emotional Support: Provide emotional support by acknowledging the patient’s concerns and exploring any underlying psychological issues contributing to anorexia, such as anxiety or depression. Psychological support or counseling may be necessary to address the root causes.
   • Monitoring and Reassessment: Regularly monitor the patient’s weight, intake, and signs of malnutrition. Adjust the care plan based on the patient’s response to interventions.
3. Evaluation: The nurse should assess whether the patient’s nutritional intake has improved, with monitoring of weight gain and the return of normal laboratory values. If the patient’s nutritional status improves, the nurse should continue to support and encourage proper nutrition while managing the underlying causes of anorexia.

 

Discuss how the nurse should plan care for a patient with “Impaired Gas Exchange” related to chronic obstructive pulmonary disease (COPD).

Answer:

Planning care for a patient with “Impaired Gas Exchange” due to chronic obstructive pulmonary disease (COPD) requires prioritizing oxygenation, managing symptoms, and minimizing complications associated with the condition.

1. Assessment: The nurse should assess the patient’s respiratory rate, oxygen saturation levels, and use of accessory muscles. Additional assessments should include auscultation of lung sounds, checking for cyanosis, and monitoring for signs of hypoxia such as confusion, restlessness, or tachycardia.
2. Interventions:
   • Oxygen Therapy: Administer supplemental oxygen as prescribed to maintain oxygen saturation levels above 90%. Carefully titrate oxygen therapy to avoid carbon dioxide retention, which may worsen respiratory acidosis in COPD patients.
   • Positioning: Position the patient in a semi-Fowler’s or Fowler’s position to help maximize lung expansion. This position reduces the workload on the diaphragm and promotes better gas exchange.
   • Pulmonary Hygiene: Encourage deep breathing exercises, coughing techniques, and incentive spirometry to help clear secretions from the lungs. Assist the patient with postural drainage if needed.
   • Medications: Administer bronchodilators and corticosteroids as prescribed to open airways and reduce inflammation. Monitor for side effects, especially those related to systemic steroids such as fluid retention or elevated blood glucose levels.
   • Education: Educate the patient on breathing techniques, including pursed-lip breathing, to help maintain airway patency and reduce dyspnea. Provide information on avoiding respiratory irritants, such as smoking and pollutants.
3. Evaluation: The nurse should evaluate the effectiveness of oxygen therapy by monitoring oxygen saturation and observing the patient’s respiratory status. The patient should show signs of improved gas exchange, such as reduced dyspnea, stable vital signs, and improved oxygen saturation levels. The nurse should continue to monitor the patient for complications such as respiratory infections or further exacerbations of COPD.

 

How should the nurse plan care for a patient with “Impaired Physical Mobility” related to a stroke?

Answer:

Planning care for a patient with “Impaired Physical Mobility” due to a stroke involves promoting safe mobility, preventing complications related to immobility, and maximizing the patient’s functional independence.

1. Assessment: The nurse should assess the extent of the patient’s mobility impairment by observing motor function, strength, and coordination. The nurse should also assess the patient’s level of consciousness and ability to follow commands, as these factors may impact mobility.
2. Interventions:
   • Encourage Early Mobilization: As appropriate, begin passive and active range-of-motion exercises to prevent contractures and promote joint flexibility. Gradually increase the patient’s activity level to improve strength and mobility.
   • Assistive Devices: Assess for the need for assistive devices such as walkers, canes, or wheelchairs to promote independence and mobility. Ensure the patient is properly fitted for any necessary devices.
   • Safety Measures: Implement fall precautions and ensure a safe environment. Keep the patient’s room clear of obstacles, and use side rails, non-slip footwear, and proper transfer techniques to prevent falls.
   • Physical Therapy: Refer the patient to physical therapy for further evaluation and interventions aimed at improving mobility. This may include strengthening exercises, gait training, and balance therapy.
   • Skin Integrity: Reposition the patient regularly to prevent pressure ulcers, as immobility increases the risk of skin breakdown. Use pressure-relieving devices as needed.
3. Evaluation: The nurse should evaluate the patient’s mobility progress by observing improvements in muscle strength, coordination, and the ability to perform activities of daily living (ADLs). Continue to reassess the patient’s mobility and adjust the care plan to meet evolving needs.

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