When should a nurse perform an ongoing assessment during a patient's hospital stay?

Only at the beginning of the hospital stay to establish a baseline.

Once a week during routine rounds.

At each shift change to identify any changes in the patient's condition.

Only when the patient reports new symptoms.

Answer and Explanation

The Correct Answer is C

A. Only at the beginning of the hospital stay to establish a baseline. This is incorrect because while an initial assessment establishes a baseline, ongoing assessments are necessary to monitor changes in the patient’s condition.

B. Once a week during routine rounds. This is incorrect because patient conditions can change rapidly, and weekly assessments are insufficient for monitoring acute care patients.

C. At each shift change to identify any changes in the patient's condition. This is correct because ongoing assessments should be performed regularly, especially at the beginning of each shift. This allows the nurse to detect changes early, adjust care plans, and intervene as needed.

D. Only when the patient reports new symptoms. This is incorrect because waiting for a patient to report symptoms may delay critical interventions. Many conditions, such as sepsis or respiratory distress, can progress without the patient immediately recognizing symptoms. Routine monitoring helps identify early signs of deterioration.

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Correct Answer is C

Explanation

A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight. This is incorrect because "Inability to Ingest Food" is not a NANDA-I approved nursing diagnosis.

B. Caregiver Role Strain, related to depression, as evidenced by constant crying. This is incorrect because "depression" is a medical diagnosis and not an appropriate etiology for a nursing diagnosis. Nursing diagnoses should be based on nursing-related causes.

C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area. This is correct because it follows the correct NANDA-I format:

Diagnosis: Impaired Skin Integrity

Etiology (related to): Physical immobility

Defining characteristics (as evidenced by): Skin tear over the sacral area

D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain. This is incorrect because "Bowel Obstruction" is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on patient responses, such as "Risk for Impaired Bowel Elimination."

A. Assisting a client with activities of daily living B. Administering intravenous fluids C. Collaborating with the interprofessional healthcare team D. Assessing client's pain level E. Administering medication as prescribed by the physician

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.

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When should a nurse perform an ongoing assessment during a patient's hospital stay?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

Correct Answer is C

Explanation

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

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

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?

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?

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

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)