The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Implement an intervention.

Perform an assessment

Develop a nursing diagnosis.

Evaluate an outcome.

Answer and Explanation

The Correct Answer is D

A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.

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Correct Answer is D

Explanation

A) Light palpation of the abdominal right lower quadrant: While light palpation is generally the first step in an abdominal examination to assess for tenderness or abnormalities, the presence of pain with deep palpation of the right kidney indicates a more specific concern. This may warrant further investigation related to the kidney rather than focusing on the lower quadrant.
B) Auscultate sounds in the abdominal left lower quadrant: Auscultation is typically done before palpation to assess bowel sounds and other abnormalities. However, given the specific complaint of pain in the right kidney area, the priority should be addressing the suspected kidney issue rather than auscultating another quadrant.
C) Deep palpation of the abdominal left upper quadrant: Deep palpation in another quadrant is not immediately relevant to the complaint of pain in the right kidney. Instead, it’s crucial to focus on assessing the area directly related to the client's symptoms.
D) First percussion of the costovertebral angles: Percussion of the costovertebral angles (CVA) is a specific technique used to assess kidney tenderness and is appropriate for evaluating the potential causes of the pain in the right kidney. This examination can help determine if the pain is due to conditions like kidney infection or inflammation. Therefore, it is the most relevant next step in this situation.

A. Background B. Person C. Situation D. Place E. Time

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

Explanation

A) Background: Orientation to "background" is not a standard component of the "AOX3" (alert and oriented times three) assessment. Typically, orientation assessments focus on more specific elements such as person, place, and time, rather than background information.
B) Person: Orientation to "person" means that the patient is aware of who they are. This is a key aspect of the AOX3 assessment, which checks whether the patient can identify themselves correctly.
C) Situation: While awareness of the situation or current circumstances is important, "situation" is not included in the standard AOX3 assessment. The usual components are person, place, and time.
D) Place: Orientation to "place" means the patient knows where they are. This is a critical component of the AOX3 assessment, indicating that the patient can identify their current location.
E) Time: Orientation to "time" means that the patient is aware of the current date, day of the week, and time of day. This is another essential part of the AOX3 assessment, reflecting the patient's awareness of the temporal context.

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The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While conducting an abdominal physical examination, the client complains of pain with deep palpation of the right kidney. Which of the following should be the nurse's next step in the physical examination?

Correct Answer is D

Explanation

The nurse reads in the patient chart the doctor's day round note. The doctor writes AOX3, the nurse knows this means the patient is oriented to: Select all that apply.

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

Explanation

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