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 D

Explanation

Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats..

A. The nurse requests that the primary health care provider examines the patient. B. The patient has a fractured right leg with a cast that was applied 2 days ago. C. The patient’s toes are cool and pale and the patient reports that the foot feels numb. D. The patient is reporting severe pain 1 hour after pain medication was given.

Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because the nurse requests that the primary health care provider examines the patient is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The nurse's request is part of the “R”, which stands for recommendation, which is the action that the nurse suggests or requests.

Choice B reason: This is the correct choice because the patient has a fractured right leg with a cast that was applied 2 days ago is the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's fracture and cast are part of the patient's background that the nurse should share with the primary health care provider.

Choice C reason: This is an incorrect choice because the patient’s toes are cool and pale and the patient reports that the foot feels numb is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's toes and foot are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

Choice D reason: This is an incorrect choice because the patient is reporting severe pain 1 hour after pain medication was given is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's pain and medication are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

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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

The nurse notes that the patient’s radial pulse is irregular. What is the most appropriate first action of the nurse?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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