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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect. The Agency for Healthcare Research and Quality is a federal agency that supports research and improvement of health care quality and safety, but it does not provide treatment guidelines for acetaminophen overdose.
Choice B reason: This is correct. The American Association of Poison Control Centers is a national organization that provides poison information and treatment recommendations through a network of poison centers. The nurse can call the poison center at 1-800-222-1222 to get expert advice on how to manage the patient who took 60 acetaminophen tablets.
Choice C reason: This is incorrect. The Centers for Disease Control and Prevention is a federal agency that monitors and prevents diseases and public health threats, but it does not provide treatment guidelines for acetaminophen overdose.
Choice D reason: This is incorrect. The Institute for Safe Medication Practices is a nonprofit organization that promotes safe medication practices and error prevention, but it does not provide treatment guidelines for acetaminophen overdose.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because the axillary method is not the most accurate measurement of the core temperature. The axillary method involves placing a thermometer under the patient's armpit and measuring the temperature of the skin surface. This method can be affected by factors such as sweating, clothing, and ambient temperature. The axillary method can underestimate the core temperature by 0.5°C to 1.5°C¹.
Choice B reason: This is an incorrect choice because the oral method is not the most accurate measurement of the core temperature. The oral method involves placing a thermometer in the patient's mouth and measuring the temperature of the sublingual pocket. This method can be affected by factors such as eating, drinking, smoking, and mouth breathing. The oral method can underestimate the core temperature by 0.3°C to 0.8°C¹.
Choice C reason: This is the correct choice because the rectal method is the most accurate measurement of the core temperature. The rectal method involves inserting a thermometer into the patient's rectum and measuring the temperature of the rectal mucosa. This method reflects the temperature of the blood flowing through the core of the body. The rectal method is considered the gold standard for measuring the core temperature¹.
Choice D reason: This is an incorrect choice because the forehead method is not the most accurate measurement of the core temperature. The forehead method involves placing a thermometer on the patient's forehead and measuring the temperature of the temporal artery. This method can be affected by factors such as sweating, hair, and ambient temperature. The forehead method can overestimate or underestimate the core temperature by 0.5°C to 1°C¹.
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