A nurse is reviewing a patient's SOAP note during shift report. The subjective data include the patient's report of abdominal pain and nausea. The objective data show a temperature of 38.5°C, elevated white blood cell count, and abdominal tenderness. The assessment states "possible appendicitis," and the plan includes preparing the patient for surgery and monitoring vital signs, Which nursing action best reflects appropriate use of the SOAP note information?
Wait for additional laboratory results before taking any action to avoid unnecessary interventions.
Prioritize preparing the patient for surgery and notify the surgical team immediately.
Document only the subjective and objective data and defer assessment until the physician evaluates the patient.
Focus solely on monitoring vital signs as outlined in the plan, since it is the only objective task specified.
The Correct Answer is B
Rationale:
A. Wait for additional laboratory results before taking any action to avoid unnecessary interventions is incorrect because the patient’s vital signs, elevated temperature, abdominal tenderness, and elevated WBC count indicate a potentially urgent condition. Delaying action could worsen the patient’s outcome if appendicitis progresses to perforation or sepsis.
B. Prioritize preparing the patient for surgery and notify the surgical team immediately is correct because the SOAP note provides actionable information: subjective complaints of pain and nausea, objective findings of fever and leukocytosis, and the assessment of possible appendicitis. Immediate communication with the surgical team and preparation for surgery align with the priority of patient safety and timely intervention in potentially acute surgical conditions.
C. Document only the subjective and objective data and defer assessment until the physician evaluates the patient is incorrect because the nurse’s role includes interpretation and action based on assessment data. Waiting without communicating the findings or taking preparatory actions could delay urgent care.
D. Focus solely on monitoring vital signs as outlined in the plan, since it is the only objective task specified is incorrect because the plan also includes preparing for surgery, which is time-sensitive. Limiting nursing action to vital signs alone ignores the urgency of the patient’s condition and the critical thinking required in acute care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Total daily dose: 2 grams = 2000 mg
Given every 6 hr → 4 doses/day
Dose per administration = 2000 mg ÷ 4 = 500 mg per dose
Available: 250 mg per capsule
Number of capsules per dose = 500 ÷ 250 = 2 capsules
Final Answer: 2 capsules
Correct Answer is D
Explanation
Rationale:
A. Teach a client about low-sodium foods is incorrect because client education requires nursing judgment, assessment of learning needs, and evaluation of understanding. These responsibilities are within the scope of the registered nurse (RN) and cannot be delegated to APs.
B. Perform wound irrigation for a client is incorrect because wound irrigation is considered a sterile procedure that requires nursing knowledge and judgment to assess the wound, prevent infection, and respond to complications. This task cannot be safely delegated to APs.
C. Evaluate pain relief for a client following the administration of a pain medication is incorrect because evaluating pain relief involves clinical assessment and professional judgment. Only an RN can determine the effectiveness of interventions and modify the plan of care accordingly.
D. Measure and record intake and output for a client is correct because this task involves collecting objective data, which is within the scope of practice for assistive personnel. The RN can then use this data to make clinical decisions. Delegating this task allows the nurse to focus on responsibilities that require professional judgment, such as assessment, evaluation, and teaching.
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