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 B

Explanation

A. Prone position: This position is not suitable for administering a rectal suppository, as it does not allow for adequate access to the rectum.

B. Sim's position: This is the correct position for administering a rectal suppository. The client is placed on their left side with the right knee flexed, which facilitates access to the rectum and allows for easier insertion of the suppository.

C. Lying on the right side: This position is less effective than Sim's position for rectal suppository insertion. Sim's position (left side) is preferred to provide better access to the rectum.

D. Supine: This position is inappropriate for rectal suppository insertion because it does not adequately expose the rectal area for insertion

A. Hemolysis B. Urticaria C. Fever D. Fluid overload

Correct Answer is B

Explanation

A. Hemolysis: This is a severe reaction to blood transfusion involving the destruction of red blood cells and requires different management strategies.

B. Urticaria: Diphenhydramine is used to prevent or treat urticaria (hives), which is a mild allergic reaction and can be managed with antihistamines.

C. Fever: This is typically managed with antipyretics or by addressing the underlying cause rather than antihistamines.

D. Fluid overload: This condition requires management with diuretics and careful monitoring of fluid intake rather than antihistamines.

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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 nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for Insertion of the suppository?

Correct Answer is B

Explanation

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Correct Answer is B

Explanation

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?

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 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?

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