Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

a head-to-toe assessment

subjective data collection

objective data collection

Maslow's Hierarchy of Needs

Coughed up 5 mL yellow sputum

Answer and Explanation

The Correct Answer is A

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

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Correct Answer is D

Explanation

A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.

B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.

C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.

D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.

A. Repeat the details of the prescription back to the provider B. Record the reason for the call made to the provider and the results of the call in the Nurses Notes C. Tell the charge nurse that the provider has prescribed morphine by telephone D. Refuse to accept the verbal prescription because this is not an emergency

Correct Answer is ["A","B"]

Explanation

A. Repeat the details of the prescription back to the provider: Verbal/telephone orders must be read back to ensure accuracy (known as read-back verification).

B. Record the reason for the call made to the provider and the results of the call in the Nurse’s Notes: Documentation should include:

Why the call was made
Provider’s response and order
Patient’s condition before and after intervention

C. Tell the charge nurse that the provider has prescribed morphine by telephone: While communication with the charge nurse is good practice, it does not replace proper documentation and verification.

D. Refuse to accept the verbal prescription because this is not an emergency: While verbal orders should be limited to emergencies, they can be accepted in certain non-emergency cases, provided read-back verification and documentation are done.

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Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

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Naxlex Comprehensive Predictor Exams

A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:

Correct Answer is D

Explanation

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

Clarify the primary purpose of nursing orders:

One benefit of computerized charting is that:

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

When using the SOAP method of charting, S stands for subjective data which means:

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an: