A patient has been transferred to your unit. The transferring nurse has given you a report on the patient's condition and helped you settle them in bed. Your next priority would be to:
Check the MAR or eMAR to see what medications they are receiving.
Read all the orders the primary care provider has written.
Document the transfer in the medical record.
Perform a head-to-toe assessment.
The Correct Answer is A
A. Checking the Medication Administration Record (MAR) or electronic MAR (eMAR) is a priority to ensure continuity of care and administer medications as prescribed in a timely manner.
B. Reviewing the orders is important but may not be the immediate priority compared to ensuring the patient's medication needs are addressed.
C. Documenting the transfer in the medical record is essential but may be done after the initial assessment and administration of necessary medications.
D. Performing a head-to-toe assessment is important but typically comes after addressing immediate needs such as medication administration, especially if the patient has specific medication schedules.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Salt substitutes often contain potassium chloride, which can significantly increase potassium intake. For someone on a low-potassium diet, it's essential to avoid these substitutes.
B. Molasses does not inherently have a higher potassium content than sugar, so this substitution does not significantly impact potassium intake.
C. Orange juice typically has a higher potassium content than apple juice, so this recommendation could increase potassium intake, contrary to a low-potassium diet.
D. Granola can contain varying amounts of potassium depending on the ingredients, so it might not always align with a low-potassium diet.
Correct Answer is D
Explanation
A. Writing dietary goals or objectives usually comes after the assessment phase when the nurse and client set specific objectives based on the assessment findings.
B. Collaborating with the client to determine interventions is a crucial step in the planning phase that follows the assessment phase.
C. Developing a nutritional nursing diagnosis is part of the diagnostic phase and might come after the assessment, where data are analyzed to identify nutrition-related problems.
D. Physical measures of a person's size, form, and functional capacities, including height, weight, body mass index (BMI), skinfold thickness, etc., are fundamental aspects of a nutritional assessment.
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