Which patient's needs must be addressed first by the nurse?

The patient who is nauseated and vomiting after receiving narcotic pain medication.

The constipated patient who needs to use the toilet after receiving a laxative.

The patient who is waiting for discharge teaching in order to go home.

The patient with chest pain and shortness of breath after two doses of sublingual nitroglycerin.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Nausea and vomiting after narcotic pain medication, while uncomfortable, are often expected side effects. The nurse should address these symptoms with antiemetics or other comfort measures, but this is generally not the highest priority unless the vomiting is severe or leads to dehydration or electrolyte imbalance.

Choice B rationale

A constipated patient needing to use the toilet should be assisted promptly for comfort and to prevent further complications. However, this need is generally not life-threatening and can usually be addressed after more urgent issues.

Choice C rationale

A patient waiting for discharge teaching is important, but discharge planning can typically be done once the patient is stable and other immediate needs are addressed. While timely discharge is a goal, it is not the priority when a patient is experiencing acute distress.

Choice D rationale

Chest pain and shortness of breath after nitroglycerin administration are signs of potential serious cardiovascular or respiratory compromise. Nitroglycerin should relieve chest pain; if it persists or worsens with shortness of breath, it could indicate worsening angina, myocardial infarction, or an adverse reaction to the medication. This situation requires immediate assessment and intervention as it poses an immediate threat to the patient's well-being.

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Correct Answer is ["C","D","E"]

Explanation

Choice A rationale

Data contained within a client's medical record is not for unrestricted sharing among all employees within a healthcare facility. Access to patient information is need-to-know based and role-specific, guided by HIPAA regulations and facility policies to protect patient privacy and confidentiality.

Choice B rationale

Documentation should primarily focus on objective data, nursing interventions performed, and the client's responses. The nurse's interpretation of the client's situation should be based on factual observations and assessments, clearly documented as such, rather than subjective opinions presented as facts.

Choice C rationale

A medical record serves as a legal document that can be used as evidence in a court of law. Accurate and complete documentation provides a chronological account of the patient's care, which can be crucial in legal proceedings to demonstrate the care provided and adherence to standards.

Choice D rationale

Timely, organized, and complete documentation is essential for effective communication among healthcare team members and for providing safe and quality patient care. Accurate and up-to-date records ensure continuity of care and reflect the patient's current status and interventions.

Choice E rationale

When subjective information, such as the client's feelings or statements, is documented, it should be clearly identified as such using quotes or phrases like "client states.”. This distinguishes subjective data from objective findings and ensures clarity in the medical record. .

A. The patient refused breakfast after vomiting 200 mL green emesis. B. The patient reports having sharp, burning pain with urination. C. The patient's catheter drained 400 mL of urine during the last 8 hours. D. The patient complains of extreme nausea upon awakening.

Correct Answer is ["B","D"]

Explanation

Choice A rationale

"The patient refused breakfast after vomiting 200 mL green emesis" is objective data. Vomiting and the amount and color of emesis are observable and measurable facts that can be directly assessed by the nurse.

Choice B rationale

"The patient reports having sharp, burning pain with urination" is subjective data. Pain is a symptom experienced and described by the patient; it cannot be objectively measured or directly observed by the nurse. The description of the pain (sharp, burning) is the patient's personal perception.

Choice C rationale

"The patient's catheter drained 400 mL of urine during the last 8 hours" is objective data. The amount of urine output via a catheter is a measurable quantity that the nurse can directly observe and record.

Choice D rationale

"The patient complains of extreme nausea upon awakening" is subjective data. Nausea is a feeling reported by the patient and is a subjective experience. The intensity ("extreme") is also based on the patient's personal perception.

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Which patient's needs must be addressed first by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

(Select All that Apply.) Information recorded in the client's medical record must be accurate and complete.A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse.Which of the following should the charge nurse include in the teaching? (Select 3 options)

Correct Answer is ["C","D","E"]

Explanation

Correct Answer is ["B","D"]

Explanation

A nurse is documenting in a client's information using the subjective, objective, assessment, and plan (SOAP) charting model.Which of the following should be included in the subjective data?

A nurse is preparing to document a client's information in the electronic medical record.Which of the following nursing statements identifies the purpose of documentation?

The nurse realizes that the wrong vital signs were recorded on a patient's chart.How will the nurse correct this error?

Fluid volume deficit related to:

The client in room 108 has been prescribed new pain medication.A nurse is providing change-of-shift report to the oncoming nurse.Which of the following information should the nurse include in the report?

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Calculate the intake for the 6 AM to 6 PM shift. A patient consumes 8 oz of a popsicle and 80 mL of ice chips during the shift. Intravenous fluids infused at 150 mL/hr during the shift. The Foley catheter was emptied of 800 mL at 1 AM & 925 mL at 6 PM. 80 mL were emptied from a drain at 6 PM.