A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

A patient who had surgery two days ago and is learning how to change the dressing

A patient who was admitted 30 minutes ago for chest pain

A patient who received pain medication 10 minutes ago

A patient who is being transferred to a long term care facility this afternoon

Answer and Explanation

The Correct Answer is B

A. A patient who had surgery two days ago and is learning how to change the dressing. This is incorrect because this patient is stable and requires routine education, which is not an immediate priority.

B. A patient who was admitted 30 minutes ago for chest pain. This is correct because chest pain can indicate a life-threatening condition such as myocardial infarction. The nurse should assess this patient immediately, monitoring for signs of cardiac compromise and initiating emergency interventions if necessary.

C. A patient who received pain medication 10 minutes ago. This is incorrect because this patient is already receiving treatment, and there is no indication of urgent distress requiring immediate intervention.

D. A patient who is being transferred to a long-term care facility this afternoon. This is incorrect because transfer preparation is not an urgent priority compared to an unstable or potentially critical patient.

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Correct Answer is B

Explanation

A. The diagnosis is not necessarily complex.

B. Nursing diagnoses should be objective and free from judgment. "Laziness" is subjective and inappropriate.

C. No legal issue is present, but professionalism is lacking.

D. The issue is more about the judgmental phrasing than missing data.

A. Involve the multidisciplinary team B. Involve the family members C. Get patient input when making the plan D. Start planning at admission

Correct Answer is C

Explanation

A. While teamwork is crucial, patient input should come first to ensure the plan aligns with their needs and capabilities.

B. Family involvement is beneficial, but the patient should have the primary role in decision-making.

C. Effective discharge planning is patient-centered, ensuring that goals align with their preferences, abilities, and resources.

D. Although discharge planning should begin at admission, the most important factor for success is patient involvement.

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A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

Correct Answer is B

Explanation

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

Correct Answer is C

Explanation

Which of the following signs is most indicative of impaired skin integrity?

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A nurse takes a health history, measures vital signs and conducts a physical assessment on a new admission. After data analysis, what should the nurse do next?

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

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