Which of the following is the most appropriate open-ended question to begin a nursing assessment?

"Is this your first time experiencing these symptoms?"

"Do you have any allergies?"

"Can you describe what brought you to the hospital today?"

"Are you feeling any pain right now?"

Answer and Explanation

The Correct Answer is C

A. This is a closed-ended question that leads to a simple "yes" or "no" response, limiting the amount of information the nurse gathers.

B. While this is important information, it is not an appropriate opening question for a full nursing assessment, as it does not encourage the patient to share their primary concern.

C. This open-ended question allows the patient to provide a detailed narrative, helping the nurse gather a comprehensive history.

D. This is a closed-ended question that focuses only on pain rather than encouraging the patient to share their full reason for seeking care.

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Correct Answer is A

Explanation

A. This is a routine, non-clinical task that does not require nursing judgment and can be safely delegated to NAP to help prevent pressure injuries.

B. Assessment is a nursing responsibility and cannot be delegated to NAP. Only a licensed nurse can evaluate the skin’s condition.

C. Wound care requires nursing expertise to ensure proper application and monitoring for signs of infection.

D. Dressing changes require clinical assessment and are outside the scope of NAP practice.

A. Assessment B. Evaluation C. Diagnosis D. Planning

Correct Answer is B

Explanation

A. Assessment. This is incorrect because assessment refers to the initial data collection before interventions are performed. The nurse auscultating the lungs after administering the medication is part of evaluating the effectiveness of treatment.

B. Evaluation. This is correct because evaluation involves determining whether the intervention was successful in achieving the desired outcome. The nurse is assessing lung sounds to determine if the inhaled medication improved airway clearance and breathing.

C. Diagnosis. This is incorrect because diagnosis involves identifying the patient's health problems based on assessment data. The nurse is not formulating a diagnosis in this scenario but rather checking the response to treatment.

D. Planning. This is incorrect because planning involves setting patient goals and selecting interventions before implementation. The nurse auscultating lung sounds after treatment is an evaluation step, not a planning step.

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Which of the following is the most appropriate open-ended question to begin a nursing assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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)?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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

A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

A nurse educator is reviewing guidelines for writing an outcome statement. Which examples best indicate a correct outcome statement? (Select All that Apply.)

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

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

When should a nurse perform an ongoing assessment during a patient's hospital stay?