A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Review the patient's medication history for any potential drug interactions.

Educate the patient about the potential side effects of the new medication.

Document the patient's baseline blood pressure before starting the medication.

Assess the patient's blood pressure to determine if the medication is effective.

Answer and Explanation

The Correct Answer is D

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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Correct Answer is A

Explanation

A. Problem identified during assessment. This is correct because in the PIE documentation format, "P" stands for "Problem," which refers to the nursing diagnosis or issue identified based on assessment findings. This section describes the primary concern that requires intervention.

B. Interventions planned for the patient. This is incorrect because interventions are documented under the "I" (Intervention) section of the PIE format, which outlines the nursing actions taken to address the identified problem.

C. Patient’s subjective complaints. This is incorrect because subjective complaints contribute to the assessment but do not represent the complete "Problem" component of the PIE format. The problem should be stated as a nursing diagnosis or issue based on assessment data.

D. Evaluation of care provided. This is incorrect because evaluation belongs under the "E" (Evaluation) section of the PIE format, which describes the patient's response to the interventions provided.

A. Altered Nutrition: Less Than Body Requirements B. Ineffective Coping C. Risk for Falls D. Impaired Mobility

Correct Answer is A

Explanation

A. Maslow’s hierarchy prioritizes physiological needs first, including nutrition, hydration, and oxygenation. This is the most immediate concern.

B. While mental health is important, psychosocial needs are a lower priority than basic physiological needs like nutrition.

C. Fall prevention is essential, but it is a potential problem rather than an existing physiological issue, making it a lower priority than inadequate nutrition.

D. Mobility is important, but ensuring adequate nutrition is more critical to prevent further complications such as muscle wasting and delayed wound healing.

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A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

Correct Answer is A

Explanation

A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

Correct Answer is A

Explanation

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