Question

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?

Answer 1

Correct Answers:

Administer the acetaminophen.

Rationale :

📌The nurse has verified that the client has not received acetaminophen in the past 4 hours and has a standing PRN order for 650 mg for headache.

📌Since the patient has a current need for pain relief, and the order parameters have been met, the nurse is authorized and expected to administer the medication to address the client’s symptom.

📌Timely administration of PRN medications is part of the nursing scope of practice and supports effective pain management.

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Answer 2

Correct Answers:

Interventions planned for the patient

Rationale :

📌In the PIE (Problem-Intervention-Evaluation) documentation format, the “I” refers to the nursing interventions carried out in response to the identified problem.

📌This includes actions taken, treatments performed, teaching provided, or other direct nursing care.

📌PIE format promotes focused documentation and continuity in the nursing process.

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Answer 3

Correct Answers:

Presence of a wound with partial thickness skin loss

Rationale :

☑Partial thickness skin loss is a clinical sign of impaired skin integrity, typically classified as a stage 2 pressure injury.

☑It involves loss of epidermis and part of the dermis, often manifesting as an open wound or blister.

☑This goes beyond mere redness or dryness and signals a breach in the protective barrier, requiring intervention to promote healing and prevent infection.

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Answer 4

Correct Answers:

Client's bedside

Rationale :

💥Providing handoff report at the client’s bedside promotes client-centered care, encourages transparency, and allows for visual assessment of the patient during the exchange.

💥 Bedside reporting enhances safety and accuracy, fosters client involvement, and supports immediate clarification of clinical findings between nurses.

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Answer 5

Correct Answers:

The patient will walk 50 feet with a walker unassisted by the end of the week.
The patient will demonstrate correct use of an inhaler by the end of the teaching session.
The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication-

Rationale :

📌A well-written outcome statement is:

Specific
Measurable
Achievable
Relevant
Time-bound (SMART)

📌These selected outcomes define clear, observable behaviors (e.g., walking, reporting pain level, using an inhaler) with realistic timeframes and allow for objective evaluation of client progress.

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Answer 6

Correct Answers:

Patient will have one soft, formed bowel movement by end of shift.

Rationale :

✍This outcome is specific, measurable, and achievable within the shift and directly addresses the problem of constipation.

✍It defines a clear expected result of nursing interventions related to bowel elimination and allows the nurse to evaluate whether the plan of care is effective within the shift timeframe.

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Answer 7

Correct Answers:

The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.

Rationale :

🔹Data validation involves verifying and cross-checking information before making clinical decisions.

🔹In this scenario, the nurse confirms the time of the last dressing change and observes drainage, indicating the dressing is soiled and requires replacement.

🔹This reflects sound clinical judgment based on verified data.

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Answer 8

Correct Answers:

Assessment

Rationale :

📌The assessment phase of the nursing process is the foundational stage where the nurse collects both subjective and objective data to guide individualized care.

📌Asking about potential allergies is a critical part of this process, as it informs future medication administration, diagnostic testing, and treatment planning.

📌Allergy data collection ensures patient safety and prevents adverse events, especially before exposure to contrast, medications, or materials such as latex.

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Answer 9

Correct Answers:

A patient who was admitted 30 minutes ago for chest pain

Rationale :

✅A newly admitted client presenting with chest pain requires immediate nursing attention due to the potential for acute coronary syndrome, including myocardial infarction.

✅Chest pain is considered a priority condition under ABC (Airway, Breathing, Circulation) and Maslow’s Hierarchy of Needs, which places circulatory compromise at the top.

✅Early assessment and intervention can be life-saving, making this patient the nurse’s top priority.

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Answer 10

Correct Answers:

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

Rationale :

🤞Ongoing assessments are essential for monitoring a patient’s progress or deterioration and are performed each shift or more frequently as needed.

🤞This ensures early identification of complications, facilitates timely interventions, and maintains continuity of care.

🤞It supports dynamic care planning and informs accurate handoff communication between shifts.

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RN Nur 237 fundamentals Quiz

No.

1 : 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?

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

3 : Which of the following signs is most indicative of impaired skin integrity?

4 : A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?

5 : A nurse educator is reviewing guidelines for writing an outcome statement. Which examples best indicate a correct outcome statement? (Select All that Apply.)

6 : A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

7 : Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

8 : 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?

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

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

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