A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

A patient who had surgery two days ago and is learning how to change the dressing

A patient who was admitted 30 minutes ago for chest pain

A patient who received pain medication 10 minutes ago

A patient who is being transferred to a long term care facility this afternoon

Answer and Explanation

The Correct Answer is B

A. A patient who had surgery two days ago and is learning how to change the dressing. This is incorrect because this patient is stable and requires routine education, which is not an immediate priority.

B. A patient who was admitted 30 minutes ago for chest pain. This is correct because chest pain can indicate a life-threatening condition such as myocardial infarction. The nurse should assess this patient immediately, monitoring for signs of cardiac compromise and initiating emergency interventions if necessary.

C. A patient who received pain medication 10 minutes ago. This is incorrect because this patient is already receiving treatment, and there is no indication of urgent distress requiring immediate intervention.

D. A patient who is being transferred to a long-term care facility this afternoon. This is incorrect because transfer preparation is not an urgent priority compared to an unstable or potentially critical patient.

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

Explanation

A. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs independently.

B. IV fluids require a provider’s order.

C. Collaboration is not an independent intervention.

D. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs and assess pain independently.

E. Administering prescribed medication requires an order.

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

Correct Answer is B

Explanation

A. Planning. This is incorrect because the planning phase involves setting goals and determining interventions based on the assessment data. Allergy information should be collected before this phase.

B. Assessment. This is correct because the assessment phase involves gathering subjective and objective data about the patient. Asking about allergies is part of the initial health history to ensure safe care planning.

C. Implementation. This is incorrect because the implementation phase involves carrying out interventions based on the data collected in the assessment. Checking allergies before giving medications or treatments should occur earlier.

D. Evaluation. This is incorrect because evaluation involves determining the effectiveness of interventions. Allergy assessment should be completed long before this phase to prevent potential reactions.

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A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

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

Explanation

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

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A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?

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