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 A
Explanation
A. Maslow’s hierarchy prioritizes physiological needs first, including nutrition, hydration, and oxygenation. This is the most immediate concern.
B. While mental health is important, psychosocial needs are a lower priority than basic physiological needs like nutrition.
C. Fall prevention is essential, but it is a potential problem rather than an existing physiological issue, making it a lower priority than inadequate nutrition.
D. Mobility is important, but ensuring adequate nutrition is more critical to prevent further complications such as muscle wasting and delayed wound healing.
Correct Answer is B
Explanation
A. Planning. This is incorrect because the planning phase involves setting goals and determining interventions based on the assessment data. Allergy information should be collected before this phase.
B. Assessment. This is correct because the assessment phase involves gathering subjective and objective data about the patient. Asking about allergies is part of the initial health history to ensure safe care planning.
C. Implementation. This is incorrect because the implementation phase involves carrying out interventions based on the data collected in the assessment. Checking allergies before giving medications or treatments should occur earlier.
D. Evaluation. This is incorrect because evaluation involves determining the effectiveness of interventions. Allergy assessment should be completed long before this phase to prevent potential reactions.
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