The nurse is caring for a patient who came to the hospital with acute shortness of breath.
What is the priority action of the nurse as the assessment process is started?
Listen to the patient's lung sounds and check the pulse oximetry level.
Tell the patient that the physician will be in shortly to start treatment.
Pull the curtain around the bed and ensure patient privacy.
Reassure the patient that the shortness of breath will be relieved shortly.
The Correct Answer is A
Choice A rationale
Assessing the patient's respiratory status with auscultation of lung sounds and pulse oximetry provides immediate and critical information about the severity of the shortness of breath and the patient's oxygenation. This data is essential for guiding immediate interventions and further assessment. Normal pulse oximetry is typically 95-100%.
Choice B rationale
Telling the patient the physician will be in shortly does not address the immediate distress of acute shortness of breath and delays necessary assessment and intervention. It offers false reassurance without taking any immediate action.
Choice C rationale
While ensuring patient privacy is important, it is not the priority action in a situation of acute shortness of breath. Addressing the immediate physiological compromise takes precedence over privacy concerns at the initial moment of assessment.
Choice D rationale
Reassuring the patient that the shortness of breath will be relieved shortly, without any assessment or intervention, is inappropriate and potentially dangerous. It does not address the underlying cause and may delay necessary treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Sharing a password with the information system representative would violate security protocols. Passwords provide individual accountability and prevent unauthorized access to sensitive patient data. Allowing others access under your credentials compromises the system's integrity and audit trails, making it difficult to track actions and ensure data security.
Choice B rationale
Providing a password to the unit clerk would similarly breach confidentiality and security measures. Unit clerks may not have the same level of authorization or training regarding data privacy as nurses, increasing the risk of inappropriate access or misuse of patient information within the electronic health record.
Choice C rationale
Even sharing a password with the nurse manager is inappropriate. While the nurse manager is a supervisor, each individual user should have their own unique login credentials to maintain accountability and security. System access is granted based on individual roles and responsibilities, not shared passwords.
Choice D rationale
Maintaining the confidentiality of one's password is a fundamental principle of information security in healthcare. Each user is responsible for protecting their login credentials to prevent unauthorized access to patient records and ensure compliance with privacy regulations like HIPAA. This safeguards patient confidentiality and the integrity of the electronic health record.
Correct Answer is C
Explanation
Choice A rationale
Subjective opinions like "pleasant to care for" lack specific, objective data about the patient's condition or care provided. Medical documentation should focus on factual observations and interventions related to the patient's health status.
Choice B rationale
"Voiding without difficulty" is a relevant observation regarding the patient's urinary function. However, it lacks specific details such as the amount, color, or clarity of the urine, which are important for a comprehensive assessment.
Choice C rationale
This statement provides specific and objective information about the patient's pain experience. It includes the patient's self-reported pain level (6/10), the location of the pain (left temporal area), and a relevant negative finding (no relief with positioning), all contributing to a clear understanding of the patient's condition.
Choice D rationale
"Onsite looks good" is vague and lacks specific details about the condition of a particular site (e.g., surgical wound, IV insertion site). Effective documentation requires descriptive terms regarding appearance, such as color, presence of drainage, swelling, or redness.
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