Nursing Knowledge
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A nursing care plan is a written document detailing the nursing interventions that will be done to meet a client’s needs and health goals. It serves as a guide for personalized care of the client and facilitates communication in the healthcare team.
Nursing interventions are actions in a care plan, such as patient education or treatments. They are formed using patient feedback, evidence-based sources, and the nursing process.
Following the nursing diagnoses that were formed based on a thorough assessment (history, physical assessment, focused assessment), a clear plan of care goals, interventions, and desired outcomes is defined.
Nursing tip: Gather information in a logical and informed way to provide the best care possible.
Nursing tip: To address each intervention to assess quality in patient care, goals need to be SMART:
Discuss with your client which health goals they would like to achieve.
Once the client’s goals are established, nursing interventions (NIC) and standard nursing outcomes (NOC) can be used to guide patient care.
They can, for example, be presented in the nursing care plan in a column-based format:
| Goals | Nursing interventions | Nursing outcomes |
| Health goal of the client | Action that is taken to reach the goal | Result of the intervention in respect to the goal |
Examples of goals could be:
Examples of fitting nursing interventions could be:
Examples of possible outcomes could be:
Answer options:
Correct answer:
Explanation:
Cold compresses can help reduce inflammation and relieve pain in osteoarthritis. High-impact exercise and lifting weights can worsen the condition, and antibiotics are not used for osteoarthritis, as it’s not caused by an infection.
Answer options:
Correct answer:
2. Monitor weight and intake and output carefully.
Explanation:
In hypervolemia, fluid overload is a concern. Monitoring weight and intake and output allows for accurate assessment and helps guide treatment. More fluid intake would exacerbate the problem, and bronchodilators are not directly related to fluid volume management. Cardiac monitoring is not required as no cardiac problem is identified.
Answer options:
Correct answer:
3. Apply pressure to the biopsy site.
Explanation:
Applying pressure to the biopsy site helps prevent hemorrhage and facilitates clot formation. Elevating the extremity and administering antibiotics are not generally the priority interventions post-bone marrow biopsy. Ice packs, not heat, can be used for short periods of time for tenderness.
Answer options:
Correct answer:
3. Loosen or remove the tight bandage or cast.
Explanation:
Compartment syndrome is caused by increased pressure within a muscle compartment, which can compromise circulation to the area. If a tight bandage or cast is contributing to the pressure, it should be loosened or removed to alleviate the pressure. The other answers could potentially worsen the condition. The Rapid Response Team is notified for imminent deterioration, which this client is not manifesting
Answer options:
Correct answer:
2. Administer prescribed antibiotics.
Explanation:
Pyelonephritis is a bacterial infection of the kidneys that usually requires antibiotic treatment for resolution. Fluid restriction is generally not recommended; in fact, increased fluids may be encouraged. A heating pad may provide temporary relief but doesn’t treat the underlying infection. If the client does have diabetes mellitus, it does increase the risk for pyelonephritis, but no mention of this is given.
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