When admitting a patient who has just arrived on the unit with a ...

[sarasara]

When admitting a patient who has just arrived on the unit with a severe headache, what should the nurse do first?
 
  a. Complete only basic demographic data before addressing the patient's pain.
  b. Medicate the patient for the headache before doing the health history and examination.
  c. Take the initial vital signs and then address the headache before completing the health history.
  d. Inform the patient that the headache will be treated as soon as the health history is completed.

Question 2

The registered nurse (RN) cares for a patient who was admitted a few hours previously with back pain after falling. Which action can the RN delegate to unlicensed assistive personnel (UAP)?
 
  a. Finish documenting the admission assessment.
  b. Determine the patient's priority nursing diagnoses.
  c. Obtain the health history from the patient's caregiver.
  d. Take the patient's temperature, pulse, and blood pressure.

[strudel15]

Answer to Question 1

ANS: C
The patient priority in this situation will be to decrease the pain level because the patient will be unlikely to cooperate in providing demographic data or the health history until the nurse addresses the pain. However, obtaining information about vital signs is essential before using either pharmacologic or nonpharmacologic therapies for pain control. The vital signs may indicate hemodynamic instability that would need to be addressed immediately.

Answer to Question 2

ANS: D
The RN may delegate vital signs to the UAP. Obtaining the health history, documentation of the admission assessment, and determining nursing diagnoses require the education and scope of practice of the RN.