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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because release of prostaglandins lowers the patient’s heart rate and blood pressure is not a reason why acute pain is particularly dangerous for a patient having a heart attack. Prostaglandins are inflammatory mediators that are involved in pain perception and modulation, but they do not have a direct effect on the heart rate and blood pressure. In fact, some prostaglandins may have a protective role in the cardiovascular system by preventing platelet aggregation and vasodilation.
Choice B reason: This is an incorrect choice because release of substance P narrows the airways and leads to hypoxemia is not a reason why acute pain is particularly dangerous for a patient having a heart attack. Substance P is a neuropeptide that is involved in pain transmission and modulation, but it does not have a significant effect on the airways or the oxygen level. Substance P may cause bronchoconstriction in some patients with asthma or chronic obstructive pulmonary disease, but this is not a common or serious complication of acute pain.
Choice C reason: This is an incorrect choice because release of endorphins causes dangerous elevation of blood pressure is not a reason why acute pain is particularly dangerous for a patient having a heart attack. Endorphins are endogenous opioids that are involved in pain inhibition and modulation, but they do not have a major effect on the blood pressure. Endorphins may cause a slight increase in blood pressure by activating the opioid receptors in the brainstem, but this is not a significant or harmful response to acute pain.
Choice D reason: This is the correct choice because stimulation of the sympathetic nervous system will increase cardiac workload is a reason why acute pain is particularly dangerous for a patient having a heart attack. The sympathetic nervous system is part of the autonomic nervous system that is responsible for the fight-or-flight response, which is triggered by acute pain. The sympathetic nervous system will increase the heart rate, blood pressure, and cardiac contractility, which will increase the oxygen demand and consumption of the heart. This will worsen the ischemia and injury of the myocardium, and may lead to arrhythmias, heart failure, or cardiac arrest.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.
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