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. Educator: This role involves teaching clients about their health conditions, treatments, and self-care, but it does not primarily focus on protecting the client or supporting their decisions.

B. Advocate: This role involves protecting the client's rights, supporting their decisions, and ensuring that their needs and preferences are respected in the healthcare setting.

C. Caregiver: This role involves providing direct care and performing tasks related to the client's well-being, but it does not focus specifically on advocacy or protecting client rights.

D. Manager: This role involves organizing and overseeing care, coordinating with other healthcare professionals, and ensuring that resources are used effectively, rather than focusing on advocacy and client protection.

A. Glasgow results B. Intracranial pressure readings C. Code status D. Plan of care changes for upcoming shift

Correct Answer is B

Explanation

A. Glasgow results: This information would typically be included in the "Assessment" section of SBAR, as it relates to the current status of the client.

B. Intracranial pressure readings: This information is appropriate for the "Background" segment of SBAR as it provides relevant context about the client's condition that could impact the plan of care.

C. Code status: This information should be included in the "Background" section if it is relevant to the client's overall care and treatment plan, but it is not specific to the immediate context of the traumatic brain injury.

D. Plan of care changes for upcoming shift: This information belongs in the "Recommendation" or "Plan" section of SBAR, as it involves the actions or changes planned for the client’s care during the upcoming shift.

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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 assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions?

Correct Answer is B

Explanation

A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

Correct Answer is B

Explanation

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

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