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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 A

Explanation

Rationale:

A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.

B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.

C. Background provides context or history relevant to the situation but does not include current vital signs.

D. Recommendation involves suggesting actions or solutions but does not include the current condition details.

A. A client who has Guillain-Barre syndrome B. A client who has a lumbosacral spinal tumor C. A client who has systemic sclerosis D. A client who has amyotrophic lateral sclerosis (ALS)

Correct Answer is B

Explanation

Rationale:

A. A client who has Guillain-Barre syndrome requires close monitoring and specialized care due to progressive weakness and potential respiratory issues. This client's care may involve more complex needs that are beyond the AP's scope.

B. A client who has a lumbosacral spinal tumor is likely to have fewer immediate needs related to eating assistance, making this task appropriate to delegate to the AP. The client’s primary concern may be mobility or pain management, but meal assistance is a routine task.

C. A client who has systemic sclerosis may have issues with gastrointestinal motility and swallowing, requiring more careful feeding assistance and monitoring, which should be performed by the nurse.

D. A client who has amyotrophic lateral sclerosis (ALS) requires specialized care for swallowing difficulties and respiratory issues, making it inappropriate to delegate meal assistance to the AP.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

Correct Answer is B

Explanation

A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?

A volunteer assigned to the pediatric unit reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer?

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

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 receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate?

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)