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 B

Explanation

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.

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

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

Correct Answer is B

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

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