A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and organize client data.

Critically analyze client data to determine priorities.

Determine effectiveness of interventions.

Set client-centered, measurable and realistic goals.

Answer and Explanation

The Correct Answer is A

A. Collect and organize client data: The first step in the nursing process involves gathering and organizing data about the clients, which is essential for making informed decisions and planning care.

B. Critically analyze client data to determine priorities: Analysis of data and setting priorities come after the initial collection and organization of client data.

C. Determine effectiveness of interventions: Evaluating the effectiveness of interventions occurs after implementing the care plan and is not the first step in the process.

D. Set client-centered, measurable and realistic goals: Goal-setting follows the collection and analysis of data and is part of the planning phase in the nursing process.

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Correct Answer is C

Explanation

A. Notify the nurse manager: While notifying the nurse manager is important, it is not the immediate priority when a medication error occurs.

B. Complete an incident report: Completing an incident report is necessary for documentation but should not be done before ensuring the client's safety.

C. Assess the client: This is the correct first action. The nurse must first assess the client to determine if there are any immediate adverse effects or reactions to the incorrect medication.

D. Call the client's provider: While it is important to inform the provider, assessing the client's condition takes precedence to address any immediate health concerns.

A. A client who is being discharged to a long-term care facility B. A client who needs teaching prior to initiating cardiac rehabilitation activities C. A client who needs teaching about insulin self-administration D. A client who is postoperative following a lobectomy and has a chest tube

Correct Answer is D

Explanation

A. A client who is being discharged to a long-term care facility: This may involve extensive discharge teaching and planning, which may not align with the float nurse’s PACU experience.

B. A client who needs teaching prior to initiating cardiac rehabilitation activities: This requires specialized knowledge in cardiac rehabilitation and patient education.

C. A client who needs teaching about insulin self-administration: This requires specific knowledge about diabetes management and patient education.

D. A client who is postoperative following a lobectomy and has a chest tube: The float nurse from the PACU is likely familiar with postoperative care and management of chest tubes, making this client the most suitable for their expertise.

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A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives the wrong medication. The nurse who made the medication error should take which of the following actions first?

Correct Answer is C

Explanation

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

Correct Answer is D

Explanation

A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the following prescribed medications places the client at risk for orthostatic hypotension? (Select all that apply.)

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)

A nurse is providing discharge teaching to a client who has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

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

A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? (Select all that apply.)

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?