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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.
B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.
C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.
D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.
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