Which is the first action of the nurse when starting care for the patient at the beginning of the shift?

Perform a focused patient assessment.

Conduct the patient’s health history.

Create the nursing care plan for the patient.

Administer prescribed medications.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct choice because performing a focused patient assessment is the first action of the nurse when starting care for the patient at the beginning of the shift. A focused patient assessment involves collecting data about the patient's current condition, needs, and preferences. This data helps the nurse to identify any changes, problems, or risks that require immediate attention or intervention.

Choice B reason: This is an incorrect choice because conducting the patient’s health history is not the first action of the nurse when starting care for the patient at the beginning of the shift. A health history involves collecting data about the patient's past and present health status, medical history, family history, and social history. This data helps the nurse to understand the patient's background, risk factors, and health goals. A health history is usually conducted during the admission process or the initial assessment, not at the beginning of each shift.

Choice C reason: This is an incorrect choice because creating the nursing care plan for the patient is not the first action of the nurse when starting care for the patient at the beginning of the shift. A nursing care plan involves developing a set of interventions and outcomes based on the patient's assessment data, diagnosis, and goals. This plan guides the nurse to provide individualized and holistic care for the patient. A nursing care plan is usually created after the initial assessment and updated regularly throughout the care process, not at the beginning of each shift.

Choice D reason: This is an incorrect choice because administering prescribed medications is not the first action of the nurse when starting care for the patient at the beginning of the shift. Administering prescribed medications involves giving the patient the right drug, dose, route, time, and documentation according to the physician's order and the nursing standards. This action requires the nurse to check the patient's assessment data, allergies, vital signs, and laboratory results before giving the medication. Administering prescribed medications is usually done after performing a focused patient assessment, not before.

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

Explanation

Choice A reason: This is a correct choice because providing personal hygiene before bedtime is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to feel more comfortable, relaxed, and refreshed, and to reduce the risk of infection or skin breakdown.

Choice B reason: This is a correct choice because synchronizing the schedule for medications and vital signs is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to have uninterrupted sleep cycles, and to avoid unnecessary disturbances or discomforts from frequent assessments or treatments.

Choice C reason: This is an incorrect choice because administering sleep aids every night at the same time is not an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can cause dependence, tolerance, or adverse effects from the sleep aids, and may not address the underlying cause of the sleep problem. The nurse should use non-pharmacological methods to promote sleep, and administer sleep aids only as prescribed and indicated.

Choice D reason: This is a correct choice because assisting the patient to use the toilet before bed is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to avoid nocturia, which is the need to urinate at night, and to prevent urinary tract infections or incontinence.

Choice E reason: This is a correct choice because straightening and changing any soiled bed linens is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to maintain a clean, dry, and comfortable sleeping environment, and to prevent skin irritation or infection.

A. Footboard B. Bedframe C. Headboard D. Side rails

Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because tying the restraints to the footboard is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The footboard is the part of the bed that supports the foot end of the mattress. Tying the restraints to the footboard can cause the patient to slide down the bed and increase the risk of strangulation, pressure ulcers, or nerve damage.

Choice B reason: This is the correct choice because tying the restraints to the bedframe is the safest and most appropriate option when the nurse is applying soft wrist restraints to the patient. The bedframe is the metal or wooden structure that supports the mattress and the box spring. Tying the restraints to the bedframe can ensure that the restraints are secure and stable, and that the patient has enough room to move without causing injury or discomfort.

Choice C reason: This is an incorrect choice because tying the restraints to the headboard is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The headboard is the part of the bed that supports the head end of the mattress. Tying the restraints to the headboard can cause the patient to slide up the bed and increase the risk of strangulation, pressure ulcers, or nerve damage.

Choice D reason: This is an incorrect choice because tying the restraints to the side rails is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The side rails are the bars that run along the sides of the bed to prevent the patient from falling out. Tying the restraints to the side rails can cause the patient to twist or bend their wrists and increase the risk of circulation impairment, nerve damage, or skin breakdown.

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Which is the first action of the nurse when starting care for the patient at the beginning of the shift?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To promote adequate sleep for a patient who suffers from a sleep pattern disturbance, what are the most appropriate nursing interventions? (Select all that apply).

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

Explanation

Where will the restraints be tied to the patient’s bed when the nurse is applying soft wrist restraints to the patient?

Correct Answer is B

Explanation

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Which is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem?

Which is the safest sleep aid for the elderly patient with insomnia?

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Which data will the nurse categorize as objective for a patient who has just completed an assessment?

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Which bedtime action by the nurse may make it more difficult for the patient to fall asleep?