A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and organize client data.

Critically analyze client data to determine priorities.

Determine effectiveness of interventions.

Set client-centered, measurable and realistic goals.

Answer and Explanation

The Correct Answer is A

A. Collect and organize client data: The first step in the nursing process involves gathering and organizing data about the clients, which is essential for making informed decisions and planning care.

B. Critically analyze client data to determine priorities: Analysis of data and setting priorities come after the initial collection and organization of client data.

C. Determine effectiveness of interventions: Evaluating the effectiveness of interventions occurs after implementing the care plan and is not the first step in the process.

D. Set client-centered, measurable and realistic goals: Goal-setting follows the collection and analysis of data and is part of the planning phase in the nursing process.

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

Explanation

A. Question any part of the order that is unclear or inappropriate: It is important to clarify any ambiguities or inaccuracies in the prescription to ensure patient safety and proper treatment.

B. Transcribe the order into the client's health record: While this is a necessary step, it is not sufficient on its own to ensure the accuracy of the telephone prescription without verification.

C. Implement a recorded order message if the nurse can hear and understand it clearly: Implementing a recorded message is not typically part of standard protocol for ensuring accuracy.

D. Repeat the order back to the provider: This is a critical step to confirm that the order was understood correctly and to avoid errors.

E. Obtain the provider's signature within 8 hr: It is required to obtain the provider's signature on the written order within a specific timeframe (usually within 24 hours) to comply with legal and institutional policies.

A. Drop prescribed amount of medication into the conjunctival sac. B. Protect the distal portion of the eyedropper using clean technique. C. Apply pressure to the bridge of the nose after administration. D. Wipe the eye from the outer canthus to the inner canthus before instillation.

Correct Answer is A

Explanation

A. Drop prescribed amount of medication into the conjunctival sac: This is the correct action for administering eye drops. The medication should be placed in the conjunctival sac to ensure proper absorption and efficacy.

B. Protect the distal portion of the eyedropper using clean technique: While it is important to maintain aseptic technique, protecting the distal portion is less critical compared to the correct placement of the medication.

C. Apply pressure to the bridge of the nose after administration: This action is not necessary for timolol eye drops. Applying pressure to the inner canthus (not the bridge of the nose) can help reduce systemic absorption in certain situations, but it is not required for timolol.

D. Wipe the eye from the outer canthus to the inner canthus before instillation: Wiping the eye from the inner to the outer canthus is the standard practice to avoid spreading any potential contaminants.

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A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

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

Explanation

A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?

A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

A nurse is providing discharge teaching to a client who has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?