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

Only at the beginning of the hospital stay to establish a baseline.

Once a week during routine rounds.

At each shift change to identify any changes in the patient's condition.

Only when the patient reports new symptoms.

Answer and Explanation

The Correct Answer is C

A. Only at the beginning of the hospital stay to establish a baseline. This is incorrect because while an initial assessment establishes a baseline, ongoing assessments are necessary to monitor changes in the patient’s condition.

B. Once a week during routine rounds. This is incorrect because patient conditions can change rapidly, and weekly assessments are insufficient for monitoring acute care patients.

C. At each shift change to identify any changes in the patient's condition. This is correct because ongoing assessments should be performed regularly, especially at the beginning of each shift. This allows the nurse to detect changes early, adjust care plans, and intervene as needed.

D. Only when the patient reports new symptoms. This is incorrect because waiting for a patient to report symptoms may delay critical interventions. Many conditions, such as sepsis or respiratory distress, can progress without the patient immediately recognizing symptoms. Routine monitoring helps identify early signs of deterioration.

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Correct Answer is A

Explanation

A. This is a routine, non-clinical task that does not require nursing judgment and can be safely delegated to NAP to help prevent pressure injuries.

B. Assessment is a nursing responsibility and cannot be delegated to NAP. Only a licensed nurse can evaluate the skin’s condition.

C. Wound care requires nursing expertise to ensure proper application and monitoring for signs of infection.

D. Dressing changes require clinical assessment and are outside the scope of NAP practice.

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. D. The nurse elevates a leg cast when the patient reports decreased mobility

Correct Answer is A

Explanation

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. This is correct because data validation involves verifying information before taking action. The nurse gathers subjective data from the patient (time of last dressing change) and objective data (drainage) before making a clinical decision.

B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. This is incorrect because the nurse has not validated whether the pain medication can be given early or if other interventions should be attempted first.

C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. This is incorrect because the nurse has not validated whether the leg cramps are due to low potassium. Leg cramps can result from multiple causes, including dehydration or circulatory issues. Lab values should be checked first.

D. The nurse elevates a leg cast when the patient reports decreased mobility. This is incorrect because decreased mobility does not necessarily indicate the need for elevation. Data validation should include assessing for swelling, circulation, and pain before making a decision.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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)?

Correct Answer is A

Explanation

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

Correct Answer is A

Explanation

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?

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.)

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

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?

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