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The nurse is developing a plan of care for a client that is 4- days post-op following a surgical procedure, open reduction internal fixation (ORIF).  The nurse has determined Impaired Skin Integrity is a top-priority patient problem (nursing diagnosis) in the plan of care.  Which nursing interventions should be included in the client’s plan of care?  Select all that apply. 

A 72-year-old female client underwent a surgical procedure, open reduction internal fixation (ORIF), of the right hip following a fracture 4 days ago.  Which of the following clinical data is considered clinically significant and would require nursing intervention?  Select all that apply. 

Which of the following tasks is appropriate for the nurse to delegate to an experienced nursing assistant?

Mrs. Smith is one day post-op double mastectomy.  The list of patient problems are:  -Acute pain -Deficient knowledge -Risk for infection -Impaired mobility  Which of the following best prioritizes the patient problems from highest priority to lowest priority?  

A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse. Which of the following should the charge nurse include in the teaching?

Refer to the case study.  The nurse has identified Impaired Physical Mobility as a patient problem. What interventions are appropriate for the nurse to implement to address the identified problem?

A Registered Nurse is making assignments for client care to a licensed practical nurse (LPN) at the beginning of the shift. Which of the following assignments should the LPN question?

A nurse is documenting in a client’s care plan in the electronic medical record (EMR).  Which of the following nurse documentation best reflects the evaluation phase of the nursing care plan?

Using Maslow’s hierarchy of needs framework for priority setting, in which order should the nurse care for the following clients, starting with the most basic needs?

A student nurse is analyzing data to determine an appropriate patient problem. The following assessment data was noted:  Respiratory rate 32 Labored breathing, crackles in lungs, productive cough with thick yellow sputum O2 saturation 88% on room air.  Which of the following patient problems would be appropriate for this client?