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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Notify the nurse manager: While notifying the nurse manager is important, it is not the immediate priority when a medication error occurs.
B. Complete an incident report: Completing an incident report is necessary for documentation but should not be done before ensuring the client's safety.
C. Assess the client: This is the correct first action. The nurse must first assess the client to determine if there are any immediate adverse effects or reactions to the incorrect medication.
D. Call the client's provider: While it is important to inform the provider, assessing the client's condition takes precedence to address any immediate health concerns.
Correct Answer is B
Explanation
A. Glasgow results: This information would typically be included in the "Assessment" section of SBAR, as it relates to the current status of the client.
B. Intracranial pressure readings: This information is appropriate for the "Background" segment of SBAR as it provides relevant context about the client's condition that could impact the plan of care.
C. Code status: This information should be included in the "Background" section if it is relevant to the client's overall care and treatment plan, but it is not specific to the immediate context of the traumatic brain injury.
D. Plan of care changes for upcoming shift: This information belongs in the "Recommendation" or "Plan" section of SBAR, as it involves the actions or changes planned for the client’s care during the upcoming shift.
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