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A charge nurse is reviewing documentation in the medical record from a newly licensed nurse.

Exhibits

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The client has a history of major depressive disorder and alcohol use disorder. They have had previous hospitalization which has included detoxification. The client is inappropriate and is a huge fall risk. The provider has denied this RN's requests for physical or chemical restraints. Currently, the ICU and progressive care unit are full, and the client is being admitted to this medical unit. They appear 'medically stable. The client is alert, oriented to self and location. Denies pain. Sitting up in bed. The partner is at bedside and said that their spouse is always complaining or arguing

The client is inappropriate and is a huge fall risk

The provider has denied this RN's requests for physical or chemical restraints

They appear 'medically stable

The partner is at bedside and said that their spouse is always complaining or arguing

the ICU and progressive care unit are full

the client is being admitted to this medical unit

Denies pain. Sitting up in bed

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

The nurse's documentation of the client being "inappropriate" is vague and unprofessional. Additionally, using the term "huge fall risk" without a specific assessment or plan to mitigate the risk (e.g., implementing fall precautions) is not adequate documentation. Further, the nurse’s reliance on physical or chemical restraints without exploring alternative interventions suggests a need for education on restraint use and patient safety practices.

The nurse's notes reflect a subjective description of the client's behavior as 'inappropriate' and 'complaining or arguing,' which is not objective or professional. It is important for nursing documentation to remain objective and to describe observed behaviors rather than labeling them. The statement that the client is "medically stable" should be supported by objective data rather than subjective observation, and it is important to note that mental health stability is also a crucial aspect of overall health.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. A child who is experiencing sickle cell crisis may require isolation to prevent infection and avoid complications related to sickle cell disease.

B. A child who has a head injury may require specific monitoring and precautions that are not suitable for a postoperative appendectomy patient.

C. A child who has a new diagnosis of type 1 diabetes mellitus generally has a stable condition that can be managed with routine care and would be an appropriate roommate for a postoperative appendectomy patient.

D. A child who has streptococcal pharyngitis could pose an infection risk to the postoperative appendectomy patient and is better kept separate to prevent the spread of infection.

A. Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus B. Assisting a client with crutch walking following knee replacement surgery C. Evaluating the outcomes of a new postoperative client D. Developing the plan of care for a client who has an amputation

Correct Answer is B

Explanation

Rationale:

A. Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus requires a higher level of clinical judgment and is typically performed by an RN.

B. Assisting a client with crutch walking following knee replacement surgery is an appropriate task for an LPN, as it involves support with activities of daily living and mobility.

C. Evaluating the outcomes of a new postoperative client involves assessing the effectiveness of care and requires RN-level assessment skills.

D. Developing the plan of care for a client who has an amputation involves comprehensive assessment and planning, which is usually the responsibility of an RN.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?

Correct Answer is C

Explanation

A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)?

Correct Answer is B

Explanation

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which of the following responses by the nurse demonstrates assertiveness?

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?