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 B

Explanation

A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.

B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.

C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.

D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.

A. 42 year old who is due to arrive from the emergency room and has experienced a stroke B. 43 year old female who is post operative surgery and is bleeding from their wound C. 82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath D. 21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe

Correct Answer is D

Explanation

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

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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 of the following signs is most indicative of impaired skin integrity?

Correct Answer is B

Explanation

After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?

Correct Answer is D

Explanation

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

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