A charge nurse is teaching a newly licensed nurse about the facility’s computerized documentation system.

Which of the following information should the nurse include?

Answer is… C and F indicate improvement.

A The client has gained 1.8 kg (4 lb). BMI is 18.9. This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.

B The clients adult child prepares two meals per day for the client. This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.

C The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.

D The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.

E The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.

F The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.

: https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture- wrist-fracture : https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.

The correct answer is choice A. A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.

Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.

Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.

Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.