A new nurse has just admitted a patient to the Step-down Unit. She has recognized several education and implementation pieces that need to be set in place before the patient is discharged.

Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

“I will begin upon the client’s admission to the facility.”

“I will begin once the client’s insurance company approves discharge coverage.”

“I will begin 48 hr before the client’s discharge.”

“I will begin once the client’s discharge order is written.”

Answer and Explanation

The Correct Answer is A

A. “I will begin upon the client’s admission to the facility.”

Effective discharge planning should start upon the client's admission to the facility. It is an ongoing process that involves assessing the patient's needs, planning for post-discharge care, and ensuring a smooth transition from the hospital to the next level of care. Early initiation of discharge planning allows the healthcare team to address any potential barriers, educate the patient and their family, and coordinate necessary resources for a successful transition.

B. “I will begin once the client’s insurance company approves discharge coverage.”

Waiting for insurance approval may delay the discharge planning process and hinder the timely coordination of resources needed for post-discharge care.

C. “I will begin 48 hr before the client’s discharge.”

Waiting until 48 hours before discharge may not allow sufficient time to address all aspects of the discharge plan, potentially leading to rushed or incomplete preparations.

D. “I will begin once the client’s discharge order is written.”

Waiting for the discharge order may delay the start of the planning process, and effective discharge planning should be initiated earlier to ensure comprehensive and patient-centered care.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ask the client if she is having pain.

This option recognizes the potential relationship between pain and elevated blood pressure. Assessing the client for pain is crucial, as pain can contribute to increased blood pressure.

B. Request a prescription for an antianxiety medication.

This option assumes that anxiety might be the cause of the elevated blood pressure. However, without further assessment, it may not be appropriate to jump to prescribing medication for anxiety.

C. Request a prescription for an antihypertensive medication.

Initiating antihypertensive medication without further assessment may not be the most appropriate first step, especially if the elevated blood pressure is related to pain or another temporary factor.

D. Return in 30 minutes to recheck the client’s blood pressure.

While monitoring blood pressure is important, waiting 30 minutes without further assessment or intervention might delay addressing the underlying issue, especially if it is related to pain or another acute problem.

A. Edema B. Heart Rate C. Chills D. Pallor

Correct Answer is C

Explanation

A. Edema:

Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.

B. Heart Rate:

Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.

C. Chills

Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.

D. Pallor:

Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.

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Naxlex Comprehensive Predictor Exams

A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous. The nurse should apply the pulse oximeter probe to which of the following locations?

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?

A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to bypass arteries in the right leg. Which assessment should receive the highest priority?

Ordered: Hydroxyzine (Vistaril) 35 mg IM stat Available: Hydroxyzine (Vistaril) 50 mg/mL Administer: ____ ml