When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?

Frequency that the problem occurs.

Related personal values.

Relevance to the situation.

Past experience with similar problems.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- While understanding the frequency that a problem occurs can provide context to its significance and potential impact, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency alone does not ensure that the evidence collected will be directly applicable to the current situation.
B)   Incorrect- Personal values are subjective and may influence an individual's perspective, but they are not the primary consideration when gathering evidence for evidence-based decision- making. Evidence-based practice aims to rely on objective and scientifically validated information rather than personal values, which can vary greatly among individuals.
C)   Correct- The most important consideration when gathering evidence is its relevance to the specific situation at hand. Evidence must directly address the problem and clinical question, ensuring that the information collected is applicable, appropriate, and reliable for guiding decision-making in the current context.
D)   Incorrect- While past experiences can offer insights, they are not the most important consideration for evidence-based decision-making. Relying solely on past experiences may not account for new developments, changing guidelines, or unique aspects of the current situation that were not present in previous encounters.

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

Explanation

A) Incorrect - Hyperglycemia typically does not lead to weight loss. In fact, it can result in weight gain due to the body's inability to properly use glucose for energy.

B) Correct - Hyperglycemia can lead to an increased sensation of hunger as the body's cells are not effectively receiving the glucose they need for energy, causing the person to feel hungry.
C) Incorrect - Cool and clammy skin are not typical symptoms of hyperglycemia. Hyperglycemia can lead to dry skin, but it does not cause cool and clammy skin.
D) Correct - Hyperglycemia often leads to increased thirst and urination. Excess glucose in the blood can cause the kidneys to work harder to filter and eliminate the glucose, leading to increased fluid intake and subsequently increased urination.
E) Hyperglycemia can cause dehydration, leading to dry, flushed skin and sometimes headaches due to electrolyte imbalances and reduced blood flow to the brain.

A. Height and weight of client prior to admission B. Client's pain rating on a scale of 1 to 10 C. Time of last administration of pain medication D. Eﬀectiveness of last pain medication administered E. History of pain medication use during the past year F. History of pain medication use during the past year

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

Explanation

Client's pain rating on a scale of 1 to 10: This information helps assess the client's current pain level and determine the need for pain medication.

Time of the last administration of pain medication: This is important to avoid overdosing or administering pain medication too frequently. It helps ensure that pain medication is given at the appropriate time intervals.

Effectiveness of the last pain medication administered: Understanding whether the previous dose provided relief or not helps guide the choice of the next medication or dosage.

The other options are not directly related to the immediate decision of administering pain medication:

Height and weight of the client prior to admission may be part of the client's medical history but are not typically required information just before administering pain medication.

A history of pain medication use during the past year is important information but may be already documented in the client's medical records and not necessary to obtain immediately before administration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which are the nurse's best responses? Select all that apply.

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

Explanation

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

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

Explanation

The practical nurse (PN) plans to screen only high risk children for scoliosis. Which group of children should the PN screen?

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever, and cough for the last two days Which finding should alert the nurse that the child is in acute respiratory distress?

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?