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?

Delegate nursing care to the assistive personnel.

Determine the effectiveness of the plan

Identify patient centered outcomes and goals

Discuss discharge planning with the social worker

Answer and Explanation

The Correct Answer is C

A. While delegation is important, it occurs after the nurse establishes patient-centered goals and a care plan.

B. Evaluating the effectiveness occurs later in the nursing process. The nurse must first set goals and interventions before assessing their outcomes.

C. After analyzing data, the next step in the nursing process is planning, which includes setting measurable, individualized goals for the patient.

D. Discharge planning is important but comes later. The nurse must first establish patient goals and care priorities before involving other healthcare team members.

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Correct Answer is D

Explanation

A. Forcing eye contact may be culturally insensitive.

B. No psychological evaluation is warranted based solely on this behavior.

C. Assuming depression without further assessment is inappropriate.

D. In some Asian cultures, avoiding eye contact can be a sign of respect rather than an indicator of depression or psychological distress.

A. Review the patient's activity orders. B. Medicate the patient to alleviate discomfort while ambulating. C. Ask for at least two other assistive personnel to come to the room. D. Offer the patient a walker.

Correct Answer is A

Explanation

A. Before assisting a patient, especially one with mobility concerns, the nurse must verify provider orders to determine any restrictions or special considerations.

B. Administering pain medication before knowing activity restrictions could lead to falls or complications.

C. While assistance may be needed, the first priority is to check the patient's activity orders to determine the safest way to proceed.

D. Providing a walker might help, but the nurse must first confirm whether assistive devices are appropriate for the patient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Correct Answer is D

Explanation

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Correct Answer is A

Explanation

A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

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?

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?