A focused assessment should be done by the nurse in all of the following situations EXCEPT:

patient's vital signs are B/P 120/80, P 88 and R 18

non-responsive patient

disoriented patient

critically patient ill

Answer and Explanation

The Correct Answer is A

A. Patient’s vital signs are B/P 120/80, P 88, and R 18: Stable, normal vital signs do not indicate an immediate need for a focused assessment unless there is a complaint or concern.

B. Non-responsive patient: A focused neurological and airway assessment is required for an unresponsive patient.

C. Disoriented patient: Disorientation may indicate neurological issues, infection, or metabolic imbalance, requiring a focused mental status and neurological assessment.

D. Critically ill patient: Critically ill patients require frequent focused assessments based on their condition (e.g., respiratory, cardiac, or neurological).

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Correct Answer is C

Explanation

A. Omission exists: An omission means something was left out, but that does not fully explain why the projected outcome was not met.

B. Failure exists: The term failure is not a standard term in critical pathways. The situation could be due to various factors beyond "failure."

C. Variance exists: A variance occurs when the patient’s progress deviates from the expected outcome within a critical pathway. This can be positive (faster recovery) or negative (delay in progress).

D. Error exists: A variance is not necessarily an error, as some patients may require longer recovery times due to medical conditions.

A. pain B. skin integrity C. fluid volume D. knowledge deficit

Correct Answer is A

Explanation

A. Pain: Pain is the most immediate concern in this scenario. Managing pain is critical for comfort and preventing further complications.

B. Skin integrity: While skin integrity may be a concern (e.g., pressure ulcers if immobile), it is not the most urgent issue at admission.

C. Fluid volume: There is no mention of dehydration or blood loss. Fluid volume is not the primary concern.

D. Knowledge deficit: While patient education is important, managing pain takes priority over knowledge deficits in acute injuries.

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A focused assessment should be done by the nurse in all of the following situations EXCEPT:

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Naxlex Comprehensive Predictor Exams

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an:

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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