Choice A rationale

Performing a focused patient assessment at the beginning of the shift is the priority action as it allows the nurse to gather current data about the patient's condition. This assessment provides the foundation for identifying the patient's immediate needs, establishing priorities, and planning appropriate care for the shift. It ensures that any changes in the patient's status since the last shift are promptly identified and addressed.

Choice B rationale

Administering prescribed medication is an important nursing responsibility, but it should occur after the initial assessment. The assessment may reveal changes in the patient's condition that could affect the timing or appropriateness of medication administration. Prioritizing assessment ensures medication administration is safe and based on the most current patient data.

Choice C rationale

Creating the nursing plan of care is an ongoing process that is informed by the initial and subsequent patient assessments. While a plan of care guides nursing interventions, the immediate need at the start of the shift is to assess the patient's current status to ensure the plan remains relevant and addresses any new or changing needs.

Choice D rationale

Determining the patient's family history is typically part of the comprehensive admission assessment. While relevant for understanding the patient's overall health risks, it is not the priority action at the beginning of each shift. The immediate focus should be on the patient's current physical and emotional status to guide immediate care.

Choice A rationale

Nausea and vomiting after narcotic pain medication, while uncomfortable, are often expected side effects. The nurse should address these symptoms with antiemetics or other comfort measures, but this is generally not the highest priority unless the vomiting is severe or leads to dehydration or electrolyte imbalance.

Choice B rationale

A constipated patient needing to use the toilet should be assisted promptly for comfort and to prevent further complications. However, this need is generally not life-threatening and can usually be addressed after more urgent issues.

Choice C rationale

A patient waiting for discharge teaching is important, but discharge planning can typically be done once the patient is stable and other immediate needs are addressed. While timely discharge is a goal, it is not the priority when a patient is experiencing acute distress.

Choice D rationale

Chest pain and shortness of breath after nitroglycerin administration are signs of potential serious cardiovascular or respiratory compromise. Nitroglycerin should relieve chest pain; if it persists or worsens with shortness of breath, it could indicate worsening angina, myocardial infarction, or an adverse reaction to the medication. This situation requires immediate assessment and intervention as it poses an immediate threat to the patient's well-being.

Choice A rationale

"The patient is sleeping comfortably" is a subjective observation and does not provide a quantifiable measure of the patient's pain level. While comfort is important, this statement lacks specific information about the patient's pain experience and does not allow for consistent monitoring or evaluation of pain management interventions.

Choice B rationale

"The patient rated the pain at 2 on a 0-to-10 scale" is an example of appropriate pain assessment documentation. It uses a standardized pain scale, allowing the patient to quantify their pain intensity. This provides objective data that can be used to monitor changes in pain levels over time and evaluate the effectiveness of pain management strategies.

Choice C rationale

"The patient appears not to be in any pain" is a subjective interpretation by the nurse based on observation. It does not involve input from the patient about their pain experience. Pain is subjective, and a patient may be experiencing pain even if they do not outwardly appear to be in distress. Relying solely on observation can lead to underreporting and undertreatment of pain.

Choice D rationale

"The patient always complains about being in pain" is a generalization and does not provide specific information about the patient's current pain level. It can also introduce bias into future pain assessments. Each pain report should be documented objectively and based on the patient's current experience, not past complaints.

Choice A rationale

While face-to-face hand-off reports are often preferred for direct communication and clarification, they are not always the only acceptable method. Other methods, such as recorded reports or written summaries with opportunities for questions, can also be effective in ensuring continuity of care, especially in situations where face-to-face reporting is not feasible.

Choice B rationale

Providing for the continuity and individualized care of the patient is a primary purpose of hand-off reports. By sharing relevant information about the patient's current condition, care plan, and any recent changes, the hand-off ensures that the receiving nurse has the necessary information to provide consistent and tailored care.

Choice C rationale

Including an opportunity for the receiver to ask questions of the person giving the report is crucial for effective communication and to clarify any ambiguities or obtain additional details. This interactive element helps ensure that the receiving nurse fully understands the patient's situation and can provide safe and appropriate care.

Choice D rationale

Hand-off reports should include up-to-date and recent changes about the patient's condition, treatments, and any new orders or concerns. This ensures that the receiving nurse is aware of the most current information and can adjust care accordingly. Outdated information can lead to errors or omissions in care.

Choice E rationale

Hand-off reports supplement, but do not replace, formal documentation in the patient's medical record. Documentation provides a comprehensive and permanent record of the patient's care, while the hand-off report is a verbal or brief written communication to ensure a smooth transition of care between nurses. Both are essential for effective patient care and communication.

Choice A rationale

The physician is responsible for medical diagnoses, which identify diseases or medical conditions based on the patient's signs, symptoms, and diagnostic test results. While nurses use medical diagnoses to inform their care, they do not analyze data to arrive at them.

Choice B rationale

The patient provides subjective data about their health status, which is crucial information for the nurse's assessment. However, the patient does not have the clinical knowledge and expertise to analyze and interpret this data in the context of other findings to formulate a nursing diagnosis.

Choice C rationale

The nurse is responsible for collecting, analyzing, and interpreting patient data (both subjective and objective) to identify patterns, draw conclusions about the patient's health status, and formulate nursing diagnoses. Nursing diagnoses describe the patient's responses to actual or potential health problems that nurses are qualified and licensed to treat.

Choice D rationale

Therapists, such as physical therapists, occupational therapists, or respiratory therapists, focus on specific aspects of the patient's rehabilitation and treatment based on their area of expertise. While they contribute valuable data to the patient's overall care, they are not primarily responsible for formulating nursing diagnoses.

Step 1 is: Locate the section on the Penicillin G label that provides reconstitution instructions for intramuscular (IM) injection.

Step 2 is: Identify the desired dose of Penicillin G, which is 350,000 units.

Step 3 is: Examine the label to find the different dilution options and the resulting concentration (units/mL) for IM administration. The label provides the following reconstitution guidelines for IM injection:. Add 9.6 mL of sterile water for injection to yield 1,000,000 units/mL (Total volume: 10 mL). Add 4.6 mL of sterile water for injection to yield 2,000,000 units/mL (Total volume: 5 mL).

Step 4 is: Determine which dilution would be most appropriate for administering 350,000 units. Using the 1,000,000 units/mL concentration:. Volume to administer = Desired dose ÷ Concentration. Volume to administer = 350,000 units ÷ 1,000,000 units/mL = 0.35 mL. Using the 2,000,000 units/mL concentration:. Volume to administer = Desired dose ÷ Concentration. Volume to administer = 350,000 units ÷ 2,000,000 units/mL = 0.175 mL.

Step 5 is: Consider the practicalities of administering such small volumes. While both are technically correct, administering 0.35 mL is generally easier and more accurate than 0.175 mL with standard syringes. Therefore, diluting to yield 1,000,000 units/mL is the more appropriate choice. The question asks for the most appropriate diluent amount, which corresponds to this concentration. To achieve a concentration of 1,000,000 units/mL, 9.6 mL of diluent should be added.

Final Answer: The most appropriate diluent amount is 9.6 mL of sterile water for injection to yield a concentration of 1,000,000 units/mL, and then administer 0.35 mL.

Choice A rationale

A risk nursing diagnosis, such as "risk for impaired skin integrity related to inadequate nutrition," identifies a potential problem that does not currently exist but has a high probability of developing if no preventative nursing interventions are implemented. It focuses on the patient's vulnerability to a specific health problem.

Choice B rationale

All nursing diagnoses, including risk diagnoses, require the development of specific nursing interventions aimed at preventing the potential problem from occurring or minimizing its impact. These interventions are crucial for addressing the identified risk factors and promoting patient well-being.

Choice C rationale

Evaluation is a critical component of the nursing process for all nursing diagnoses. The effectiveness of the nursing interventions implemented for a risk diagnosis must be evaluated to determine if they successfully prevented the problem from developing. This ongoing assessment ensures the plan of care is appropriate and achieving the desired outcomes.

Choice D rationale

Nursing diagnoses, including risk diagnoses, are within the scope of nursing practice and guide independent nursing interventions. While collaboration with the medical team is essential for overall patient care, risk diagnoses do not inherently necessitate medical intervention as the primary focus is on preventative nursing actions.

Choice A rationale

While electronic medical record (EMR) systems aim to improve legibility by using standardized digital documentation, they do not entirely eliminate the need to interpret physician notes or other entries. There may still be instances where clarification or interpretation is required.

Choice B rationale

A significant benefit of implementing an EMR system is the potential to streamline documentation processes. Electronic charting can reduce the time nurses spend on manual tasks such as handwriting notes, transcribing orders, and locating paper records, thereby improving efficiency.

Choice C rationale

Password management and security protocols are often a necessary component of electronic systems to protect patient privacy and data integrity. Implementing a new EMR system may involve changes to password policies and frequency of updates, which could be a source of frustration rather than a benefit.

Choice D rationale

Access to a family member's medical record, even a child's, raises significant privacy and security concerns. Healthcare systems have strict regulations (e.g., HIPAA) to protect patient confidentiality, and nurses typically do not have unrestricted access to family members' records.

Choice A rationale

AC and HS is a common abbreviation in medical orders that stands for "ante cibum" (before meals) and "hora somni" (at bedtime). Therefore, "ambulate patient four times a day AC & HS" means the patient should ambulate before breakfast, before lunch, before dinner, and at bedtime.

Choice B rationale

NG is an abbreviation for nasogastric, which refers to a tube inserted through the nose into the stomach and is not related to ambulation orders.

Choice C rationale

DNR stands for "do not resuscitate," which is a medical order regarding end-of-life care and is not related to ambulation.

Choice D rationale

STAT is an abbreviation meaning "immediately" and is typically used for urgent medications or treatments, not for routine ambulation orders.

Choice A rationale

Incorrect organization of health assessment findings relates to how the nurse collects and structures patient data, which may impact the accuracy of diagnosis and care planning but is less likely to be the primary cause of frustration with a patient's cultural health practices.

Choice B rationale

While a patient's insistence on alternative remedies and spiritual practices might indicate coping mechanisms, it doesn't directly explain the nurse's frustration. The frustration likely stems from a conflict in beliefs or approaches to healthcare rather than the patient's ability to cope.

Choice C rationale

Cultural differences encompass the values, beliefs, and practices that influence a person's perception of health, illness, and healthcare. A patient's preference for herbal remedies, prayer, and a spiritual healer over conventional medical treatment reflects cultural health-related practices that may differ significantly from the nurse's professional training and beliefs, potentially leading to frustration.

Choice D rationale

Delay in psychosocial development refers to a lag in achieving expected developmental milestones related to social and emotional functioning. While it can influence a patient's health behaviors, it is less directly related to the nurse's frustration with culturally based healthcare choices. .