The nurse is caring for a trauma patient who has just arrived in the emergency room.
The nurse listens to the patient's lung sounds, palpates the patient's peripheral pulses, and obtains vital signs.
What is the best description of the nurse's actions?
Performing a physical examination.
Establishing priorities for outcomes.
Demonstrating diagnostic reasoning.
Setting time frames for interventions.
The Correct Answer is A
Choice A rationale
Performing a physical examination involves the systematic assessment of a patient's body to identify signs of health or illness. Listening to lung sounds, palpating peripheral pulses, and obtaining vital signs are all fundamental components of a physical examination aimed at gathering objective data about the patient's current condition.
Choice B rationale
Establishing priorities for outcomes involves setting goals for patient care based on identified nursing diagnoses and collaborative problems. While the nurse's assessment data will inform the development of outcomes, the initial actions described focus on data collection, not outcome identification.
Choice C rationale
Demonstrating diagnostic reasoning is the cognitive process of analyzing assessment data to arrive at a nursing diagnosis or identify a collaborative problem. While the nurse is gathering data that will contribute to diagnostic reasoning, the actions described are the data collection phase itself, not the analysis.
Choice D rationale
Setting time frames for interventions involves establishing specific schedules for nursing actions aimed at achieving patient outcomes. The nurse's immediate actions upon the patient's arrival are focused on rapid assessment to understand the patient's immediate needs, not on scheduling future interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While electronic medical record (EMR) systems aim to improve legibility by using standardized digital documentation, they do not entirely eliminate the need to interpret physician notes or other entries. There may still be instances where clarification or interpretation is required.
Choice B rationale
A significant benefit of implementing an EMR system is the potential to streamline documentation processes. Electronic charting can reduce the time nurses spend on manual tasks such as handwriting notes, transcribing orders, and locating paper records, thereby improving efficiency.
Choice C rationale
Password management and security protocols are often a necessary component of electronic systems to protect patient privacy and data integrity. Implementing a new EMR system may involve changes to password policies and frequency of updates, which could be a source of frustration rather than a benefit.
Choice D rationale
Access to a family member's medical record, even a child's, raises significant privacy and security concerns. Healthcare systems have strict regulations (e.g., HIPAA) to protect patient confidentiality, and nurses typically do not have unrestricted access to family members' records.
Correct Answer is ["0.7"]
Explanation
Step 1 is: The desired dose is 7000 units and the available concentration is 10,000 units/mL.
Step 2 is: Divide the desired dose by the available concentration: 7000 units ÷ 10,000 units/mL = 0.7 mL. Final answer: The nurse will administer 0.7 mL.
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