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 B

Explanation

Choice A rationale

Client administered nitroglycerin is objective data because it is a documented action performed by the client and can be verified. Subjective data, on the other hand, comes from the client's perspective.

Choice B rationale

Client reports chest pain after mowing the lawn this morning is subjective data because it is a statement made by the client about their experience. It describes their feelings and circumstances as they perceive them.

Choice C rationale

Client's blood pressure is 182/98 mmHg is objective data because it is a measurable physiological parameter obtained through assessment. It is a factual finding that can be directly observed and recorded.

Choice D rationale

Client's skin is pale and diaphoretic is objective data because these are observable physical signs noted by the nurse during assessment. They are factual descriptions of the client's physical condition.

A. Determine Chuck's goals and expectations regarding hospitalization. B. Establish a therapeutic relationship with Chuck and his wife. C. Identify Chuck's chief complaints, concerns, and worries. D. Ascertain which parts of the interview may require further exploration. E. Review Mr. Rhodes' past medical history in detail.

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

Explanation

Choice A rationale

Determining the client's goals and expectations regarding hospitalization is crucial for patient-centered care. Understanding what the client hopes to achieve during their stay allows the nurse to tailor the care plan to meet their individual needs and preferences, promoting adherence and satisfaction.

Choice B rationale

Establishing a therapeutic relationship with the client and their wife is fundamental for effective communication and trust. A strong rapport facilitates open dialogue, allowing the nurse to gather accurate information, provide emotional support, and involve the family in the care process.

Choice C rationale

Identifying the client's chief complaints, concerns, and worries is the primary focus of the initial interview. Understanding the main reasons for seeking healthcare helps the nurse to prioritize assessments and interventions, addressing the most pressing issues first.

Choice D rationale

Ascertaining which parts of the interview may require further exploration guides subsequent data collection. Identifying areas where more detailed information is needed ensures a comprehensive understanding of the client's health status and allows the nurse to focus on relevant aspects in follow-up interactions.

Choice E rationale

While reviewing the client's past medical history is important, it is usually a more detailed process that occurs after the initial interview to identify immediate concerns. The initial interview focuses on the present situation and the client's current perspective.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Crystal starts the data collection.What would she want to accomplish during the interview with Mr. Rhodes? (SELECT 4 CORRECT ANSWERS)

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

Explanation

An example of an appropriate nursing diagnosis is:

The establishment of priorities of care during the planning phase of the nursing process often uses the framework of:

The nurse is caring for a patient with the nursing diagnosis of ineffective airway clearance related to narrowed airways and thick sputum.Which is an appropriate expected outcome for this patient?

When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:

The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient’s chart demonstrates that the teaching was successful?

The nurse is caring for a trauma patient who has just arrived in the emergency room.The nurse listens to the patient's lung sounds, palpates the patient's peripheral pulses, and obtains vital signs.What is the best description of the nurse's actions?

The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended query will provide the nurse with helpful information about the patient's health status?

A charge nurse is reviewing the documentation completed by a newly licensed nurse.Which of the following entries should the charge nurse recommend for revision?