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. Problem identified during assessment. This is correct because in the PIE documentation format, "P" stands for "Problem," which refers to the nursing diagnosis or issue identified based on assessment findings. This section describes the primary concern that requires intervention.

B. Interventions planned for the patient. This is incorrect because interventions are documented under the "I" (Intervention) section of the PIE format, which outlines the nursing actions taken to address the identified problem.

C. Patient’s subjective complaints. This is incorrect because subjective complaints contribute to the assessment but do not represent the complete "Problem" component of the PIE format. The problem should be stated as a nursing diagnosis or issue based on assessment data.

D. Evaluation of care provided. This is incorrect because evaluation belongs under the "E" (Evaluation) section of the PIE format, which describes the patient's response to the interventions provided.

A. Risk for alteration in skin integrity B. Activity Intolerance C. Risk for Infection D. Deficient Fluid volume

Correct Answer is B

Explanation

A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.

B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.

C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.

D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.

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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

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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

A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

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)?

A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

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

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

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 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?