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 A

Explanation

A. Problem identified during assessment. This is correct because in the PIE documentation format, "P" stands for "Problem," which refers to the nursing diagnosis or issue identified based on assessment findings. This section describes the primary concern that requires intervention.

B. Interventions planned for the patient. This is incorrect because interventions are documented under the "I" (Intervention) section of the PIE format, which outlines the nursing actions taken to address the identified problem.

C. Patient’s subjective complaints. This is incorrect because subjective complaints contribute to the assessment but do not represent the complete "Problem" component of the PIE format. The problem should be stated as a nursing diagnosis or issue based on assessment data.

D. Evaluation of care provided. This is incorrect because evaluation belongs under the "E" (Evaluation) section of the PIE format, which describes the patient's response to the interventions provided.

A. The patient reports increased pain and limited range of motion B. The patient experiences frequent falls and difficulty maintaining balance C. The patient is able to independently walk with a walker D. The patient has difficulty ambulating without assistance

Correct Answer is C

Explanation

A. Increased pain and frequent falls indicate unmet outcomes.
B. Frequent falls indicate unmet outcomes.
C. This demonstrates progress toward independence in mobility.
D. Difficulty ambulating shows ongoing impairment.

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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

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

Correct Answer is A

Explanation

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Correct Answer is C

Explanation

The nurse is providing care to a patient in an acute care facility. Which of the following are examples of independent nursing interventions? (Select All that Apply.)

When should a nurse perform an ongoing assessment during a patient's hospital stay?

A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

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?

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?

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?