A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who reports a severe migraine headache

A client who has a suspected diagnosis of tuberculosis (TB)

A client who sustained a head injury and is having periods of confusion

A client who has a history of atrial fibrillation and is on continuous ECG monitoring.

Answer and Explanation

The Correct Answer is C

A.   While a severe migraine headache is certainly uncomfortable and may require medication and observation, it does not typically necessitate constant monitoring. The client might benefit from a quieter room and can often be managed effectively with scheduled visits by nursing staff. Therefore, this client does not necessarily need to be closest to the nurses' station.
B.   A client with a suspected diagnosis of TB should be placed in a negative-pressure isolation room to prevent the spread of airborne pathogens. The proximity to the nurses' station is less critical for infection control purposes. Proper isolation procedures and equipment are more important for managing TB.
C.   A client with a head injury and periods of confusion is at risk for complications such as falls, disorientation, or worsening of their condition. This client requires close monitoring to ensure their safety and to promptly address any changes in their condition. Assigning this client to a room closest to the nurses' station ensures that the staff can frequently observe and quickly respond to any potential issues.

D.   A client on continuous ECG monitoring requires regular assessment of their heart rhythm and immediate intervention if there are any abnormalities. While close monitoring is needed, this client’s condition is managed with electronic equipment that can alert staff to significant changes, so proximity to the nurses' station is less critical compared to more acute or unpredictable conditions.

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Correct Answer is B

Explanation

A. Eating 60% of breakfast is generally not a significant concern regarding the administration of antihypertensive medication. However, if the client had a significantly reduced intake or other issues, it might warrant attention, but 60% of a meal typically does not.
B. This finding is significant and indicates that further assessment is necessary before administering antihypertensive medication. Dizziness, especially when related to ambulation, could be a sign of hypotension or an adverse effect of antihypertensive medication.
C. Trouble sleeping can be related to various factors, including stress, side effects of medication, or underlying health conditions. While it is important to consider the client’s overall well-being, this finding does not immediately indicate a need for further assessment before administering antihypertensive medication.
D. Urine output of 400 mL over 8 hours indicates a urine output of 50 mL per hour, which is within the normal range for adults. This finding is unlikely to require further assessment specifically in relation to the administration of antihypertensive medication.

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

Correct Answer is D

Explanation

A. Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B. Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C. Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D. Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.

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A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?

Correct Answer is B

Explanation

A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?

Correct Answer is D

Explanation

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