A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:
a nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities.
at least three times during the shift: at the beginning, in the middle, at the end, and as needed.
an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.
at the end of the shift so that the nurse can give his full attention and time to the patient's needs during the shift.
The Correct Answer is C
A. A nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities. The nurse should assess the patient first to determine their needs and priorities rather than create a care plan without assessment.
B. At least three times during the shift: at the beginning, in the middle, at the end, and as needed. Regular documentation is good practice, but the initial assessment must be documented at the beginning of the shift to establish a baseline.
C. An initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. Documenting an initial assessment is crucial for identifying immediate needs and planning care, especially after surgery.
D. At the end of the shift so that the nurse can give full attention to the patient's needs during the shift. Waiting until the end of the shift risks missing critical changes and does not provide a clear baseline assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
A. Oral. Oral learning is not commonly identified as a distinct mode in learning styles.
B. Visual.
Visual learning involves learning through seeing materials like images, charts, or demonstrations.
C. Gustatory.
Gustatory (taste-based) learning is not a recognized major mode of learning.
D. Auditory.
Auditory learning involves learning by listening to spoken information.
E. Kinesthetic.
Kinesthetic learning involves learning through hands-on activities and physical movement.
F. Tactile. Tactile learning is closely related to kinesthetic learning but refers specifically to hands-on activities involving touch.
Correct Answer is D
Explanation
A. "I don't feel like walking today either."
This response shifts the focus from the patient to the nurse and does not encourage further discussion about the patient's reluctance or explore the reasons behind it.
B. "You have to walk today."
This statement sounds forceful and dismissive, and may make the patient feel pressured rather than supported. It does not invite dialogue or provide understanding.
C. "Why don't you want to walk today?"
This question can sound judgmental and may put the patient on the defensive. A more neutral response would help the nurse understand the patient's reluctance without pressure.
D. "You don't want to walk today?"
This response reflects the patient's own words back, validating their feelings and opening up the opportunity for the patient to explain their reasons. It is empathetic and nonjudgmental, which encourages therapeutic communication.
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