Which is the first action of the nurse when starting care for the patient at the beginning of the shift?

Perform a focused patient assessment.

Conduct the patient’s health history.

Create the nursing care plan for the patient.

Administer prescribed medications.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct choice because performing a focused patient assessment is the first action of the nurse when starting care for the patient at the beginning of the shift. A focused patient assessment involves collecting data about the patient's current condition, needs, and preferences. This data helps the nurse to identify any changes, problems, or risks that require immediate attention or intervention.

Choice B reason: This is an incorrect choice because conducting the patient’s health history is not the first action of the nurse when starting care for the patient at the beginning of the shift. A health history involves collecting data about the patient's past and present health status, medical history, family history, and social history. This data helps the nurse to understand the patient's background, risk factors, and health goals. A health history is usually conducted during the admission process or the initial assessment, not at the beginning of each shift.

Choice C reason: This is an incorrect choice because creating the nursing care plan for the patient is not the first action of the nurse when starting care for the patient at the beginning of the shift. A nursing care plan involves developing a set of interventions and outcomes based on the patient's assessment data, diagnosis, and goals. This plan guides the nurse to provide individualized and holistic care for the patient. A nursing care plan is usually created after the initial assessment and updated regularly throughout the care process, not at the beginning of each shift.

Choice D reason: This is an incorrect choice because administering prescribed medications is not the first action of the nurse when starting care for the patient at the beginning of the shift. Administering prescribed medications involves giving the patient the right drug, dose, route, time, and documentation according to the physician's order and the nursing standards. This action requires the nurse to check the patient's assessment data, allergies, vital signs, and laboratory results before giving the medication. Administering prescribed medications is usually done after performing a focused patient assessment, not before.

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Correct Answer is C

Explanation

Choice A reason: This is an incorrect choice because sleep-wake pattern is not the most important assessment to determine if a patient is receiving sufficient sleep. Sleep-wake pattern is the cycle of sleeping and waking that follows a circadian rhythm. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep-wake patterns that suit their needs and preferences.

Choice B reason: This is an incorrect choice because hours of sleep each night is not the most important assessment to determine if a patient is receiving sufficient sleep. Hours of sleep each night is the duration of sleep that a person gets in a 24-hour period. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep needs and requirements that vary according to age, lifestyle, health, and other factors.

Choice C reason: This is the correct choice because whether the patient feels rested is the most important assessment to determine if a patient is receiving sufficient sleep. Feeling rested is the subjective perception of the patient about their sleep quality and quantity. It is a reliable indicator of sleep sufficiency, as it reflects the patient's satisfaction and well-being after sleeping.

Choice D reason: This is an incorrect choice because frequency of nocturia is not the most important assessment to determine if a patient is receiving sufficient sleep. Frequency of nocturia is the number of times that a person has to urinate at night. However, it is not a reliable indicator of sleep quality or quantity, as it may be influenced by other factors such as fluid intake, medication, or medical conditions.

A. Check the patient’s order list to determine if antiemetic medication has been prescribed for the patient. B. Begin teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting. C. Provide measures to relieve the patient’s nausea and return to teach about wound care when the patient is feeling better. D. Apply a cold cloth to the patient's forehead and maintain a quiet odor-free environment for the patient. E. Document in the patient’s chart that teaching about wound care management was not done because the patient refused to learn.

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

Explanation

Choice A reason: This is a correct choice because checking the patient’s order list to determine if antiemetic medication has been prescribed for the patient is a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is important to manage the patient's nausea and prevent vomiting, which can lead to dehydration, electrolyte imbalance, and aspiration. The nurse should follow the physician's orders and administer the antiemetic medication as indicated.

Choice B reason: This is an incorrect choice because beginning teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting, is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is not appropriate to perform when the patient is feeling sick and uncomfortable, as it may impair the patient's learning ability and motivation. The nurse should postpone the teaching until the patient's nausea is resolved and the patient is ready to learn.

Choice C reason: This is a correct choice because providing measures to relieve the patient’s nausea and returning to teach about wound care when the patient is feeling better is a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is essential to address the patient's immediate need and comfort, and to ensure that the patient receives the necessary education about wound care management at a suitable time. The nurse should provide measures such as offering clear liquids, crackers, or ginger, positioning the patient in a semi-Fowler's position, and providing a basin or emesis bag if needed.

Choice D reason: This is an incorrect choice because applying a cold cloth to the patient's forehead and maintaining a quiet odor-free environment for the patient is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is a supportive measure that may help to soothe the patient's nausea, but it is not sufficient to treat the underlying cause or prevent further complications. The nurse should also check the patient's order list and administer the antiemetic medication if prescribed.

Choice E reason: This is an incorrect choice because documenting in the patient’s chart that teaching about wound care management was not done because the patient refused to learn is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is a false and inaccurate documentation that does not reflect the patient's condition or the nurse's actions. The nurse should document the patient's nausea, the interventions provided, and the plan to resume the teaching when the patient is feeling better.

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Which is the first action of the nurse when starting care for the patient at the beginning of the shift?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important to determine if a patient is receiving sufficient sleep?

Correct Answer is C

Explanation

What are the priority actions of the nurse who enters the patient’s room to begin teaching the patient about wound care management and notes that the patient is nauseated due to medication side effects? (Select all that apply).

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

Explanation

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