A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:
a nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities.
at least three times during the shift: at the beginning, in the middle, at the end, and as needed.
an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.
at the end of the shift so that the nurse can give his full attention and time to the patient's needs during the shift.
The Correct Answer is C
A. A nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities. The nurse should assess the patient first to determine their needs and priorities rather than create a care plan without assessment.
B. At least three times during the shift: at the beginning, in the middle, at the end, and as needed. Regular documentation is good practice, but the initial assessment must be documented at the beginning of the shift to establish a baseline.
C. An initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. Documenting an initial assessment is crucial for identifying immediate needs and planning care, especially after surgery.
D. At the end of the shift so that the nurse can give full attention to the patient's needs during the shift. Waiting until the end of the shift risks missing critical changes and does not provide a clear baseline assessment.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.
B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.
C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.
D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.
Correct Answer is D
Explanation
A. While safe sex practices can significantly reduce the risk of STIs, they do not eliminate the risk entirely, especially with multiple partners involved.
B. This statement is misleading; not all STIs are transmitted solely through sexual intercourse, as some can also be transmitted through non-sexual means.
C. It is important to recognize that asymptomatic individuals can still be carriers of STIs; thus, this statement may provide false reassurance.
D. Teaching the client about the importance of following the medication regimen and attending follow-up appointments is critical for effective treatment of gonorrhea and preventing further transmission or complications. This approach prioritizes the client’s health and reinforces the need for responsible sexual practices.