A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Compare data with normal values and standards.

Organize data into clusters that have similar underlying causes.

Validate data by using multiple sources of information.

Document data using standardized terminology and abbreviations.

Prioritize data according to urgency and importance.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

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Correct Answer is B

Explanation

Choice A reason:

Asking about family history of heart disease or stroke is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's risk factors, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice B reason:

Asking how long the client has been feeling this way is a priority question for a client who is experiencing chest pain and shortness of breath. This question helps to determine the onset and duration of the symptoms, which are important factors for diagnosing and treating the client. For example, if the client has been feeling this way for more than 20 minutes, it may indicate a myocardial infarction (heart attack), which requires urgent intervention. Therefore, this is the best choice.

Choice C reason:

Asking about medications or supplements is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's medical history and possible drug interactions, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice D reason:

Asking what the client was doing when the pain started is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the possible triggers or precipitating factors of the symptoms, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

A. Administer nitroglycerin sublingually as ordered. B. Obtain a complete health history from the patient. C. Educate the patient about lifestyle modifications. D. Prepare the patient for cardiac catheterization.

Correct Answer is A

Explanation

Choice A reason:

Administering nitroglycerin sublingually as ordered is the next priority action for the nurse because nitroglycerin is a medication that relaxes the heart arteries and improves blood flow to the heart muscle, which can relieve chest pain and shortness of breath caused by coronary artery disease. Nitroglycerin can also lower blood pressure, which can help reduce the workload of the heart and prevent further damage to the heart muscle. Nitroglycerin is a fast-acting medication that should be given as soon as possible after chest pain occurs or is suspected.

Choice B reason:

Obtaining a complete health history from the patient is not the next priority action for the nurse because it is not an urgent intervention that can address the patient's immediate needs. A complete health history can provide valuable information about the patient's risk factors, past medical history, medications, allergies, and family history, but it can also take a long time to obtain and may not be feasible if the patient is in pain or distress. A complete health history can be obtained later after the patient's condition is stabilized and more urgent interventions are done.

Choice C reason:

Educating the patient about lifestyle modifications is not the next priority action for the nurse because it is not an acute intervention that can relieve the patient's symptoms or prevent further complications. Lifestyle modifications such as quitting smoking, eating a healthy diet, exercising regularly, managing stress, and controlling blood pressure and cholesterol levels are important for preventing or managing coronary artery disease in the long term, but they do not have an immediate effect on the patient's condition. Educating the patient about lifestyle modifications can be done later after the patient's condition is improved and the patient is ready to learn.

Choice D reason:

Preparing the patient for cardiac catheterization is not the next priority action for the nurse because it is not a definitive intervention that can confirm or rule out coronary artery disease or other causes of chest pain and shortness of breath. Cardiac catheterization is a diagnostic procedure that involves inserting a thin tube into an artery in the groin or arm and advancing it to the heart to inject contrast dye and take X-ray images of the heart and blood vessels. Cardiac catheterization can help identify blockages or narrowing in the coronary arteries that may cause chest pain and shortness of breath, but it also carries some risks such as bleeding, infection, allergic reaction, kidney damage, or heart attack. Cardiac catheterization may be ordered by the physician after other tests such as ECG, blood tests, or.

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A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an emergency assessment for a client who is experiencing chest pain and shortness of breath. Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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