A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

A patient who is scheduled for a routine follow-up visit for hypertension management.

A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene.

A patient who is recovering from an appendectomy and is asking about discharge instructions.

A patient who is complaining of sudden onset chest pain and shortness of breath.

Answer: D

Answer and Explanation

The Correct Answer is D

A. A patient who is scheduled for a routine follow-up visit for hypertension management. This is incorrect because this patient is stable and does not require immediate assessment. Routine follow-ups do not take priority over acute conditions.

B. A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene. This is incorrect because while personal hygiene is important, it is not urgent or life-threatening.

C. A patient who is recovering from an appendectomy and is asking about discharge instructions. This is incorrect because discharge teaching is important but can be scheduled later in the shift when more urgent needs have been addressed.

D. A patient who is complaining of sudden onset chest pain and shortness of breath. This is correct because sudden onset chest pain and shortness of breath can indicate a life-threatening condition such as myocardial infarction or pulmonary embolism. The nurse must immediately assess this patient to determine the cause and initiate emergency interventions if necessary.

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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. The patient will be educated about the signs of infection. B. The patient will know how to manage diabetes effectively. C. The patient will understand the importance of medication adherence. D. The patient will walk 50 feet with a walker unassisted by the end of the week. E. The patient will demonstrate correct use of an inhaler by the end of the teaching session. F. The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication.

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

Explanation

A. The patient will be educated about the signs of infection. This is incorrect because it is not specific or measurable. The statement does not describe how the nurse will evaluate whether the patient has understood the information.

B. The patient will know how to manage diabetes effectively. This is incorrect because "know" is not measurable. A better outcome statement would describe a specific action the patient will perform to demonstrate their understanding of diabetes management.

C. The patient will understand the importance of medication adherence. This is incorrect because "understand" is not an observable or measurable behavior. Instead, an outcome should describe an action the patient will take, such as demonstrating how to take medication correctly.

D. The patient will walk 50 feet with a walker unassisted by the end of the week. This is correct because it is specific, measurable, and time-bound. It describes a clear action that the nurse can assess.

E. The patient will demonstrate correct use of an inhaler by the end of the teaching session. This is correct because it is measurable and observable. The nurse can directly assess whether the patient correctly uses the inhaler.

F. The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication. This is correct because it is specific, includes a measurable criterion (pain scale), and has a clear timeframe.

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A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

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

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

Explanation

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

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

The nurse manager notices that a staff nurse writes a nursing diagnosis as "Impaired Physical Mobility, related to laziness and not having appropriate shoes." Which issue related to the nursing diagnosis will the nurse manager discuss with the staff nurse?

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

The nurse is providing care to a patient in an acute care facility. Which of the following are examples of independent nursing interventions? (Select All that Apply.)

A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?