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)?

42 year old who is due to arrive from the emergency room and has experienced a stroke

43 year old female who is post operative surgery and is bleeding from their wound

82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath

21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe

Answer and Explanation

The Correct Answer is D

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

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Correct Answer is C

Explanation

A. Outcome evaluation is part of the final phase.

B. Nursing diagnoses come after assessment.

C. The first phase of the nursing process is assessment, which includes collecting a comprehensive database of patient information.

D. Interventions occur in the implementation phase.

A. As written, the diagnosis is too complex. B. The staff nurse is being judgmental. C. The diagnosis is legally questionable. D. There is deficiency of supportive data.

Correct Answer is B

Explanation

A. The diagnosis is not necessarily complex.

B. Nursing diagnoses should be objective and free from judgment. "Laziness" is subjective and inappropriate.

C. No legal issue is present, but professionalism is lacking.

D. The issue is more about the judgmental phrasing than missing data.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

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?

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?

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.)

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

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?

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

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?