A client who had surgery 3 days ago is sitting with the head of the bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Lower the bed prior to helping the client to move up in bed.

Encourage the client to eat all of the meals that are sent.

Offer fruit juice at least twice during both the day and evening shifts.

Have the client hold a pillow over the abdomen to cough and deep breathe.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important instruction because lowering the bed reduces the risk of injury to both the client and the UAP. It also makes it easier for the UAP to use proper body mechanics and leverage when assisting the client to move up in bed.

Choice B reason: This is not the most important instruction because encouraging the client to eat all of the meals that are sent is not directly related to repositioning the client. While adequate nutrition is important for wound healing and recovery, the nurse should assess the client's appetite, dietary needs, and preferences before instructing the UAP to encourage the client to eat.

Choice C reason: This is also not the most important instruction because offering fruit juice at least twice during both the day and evening shifts is not directly related to repositioning the client. While adequate hydration is important for preventing constipation and promoting circulation, the nurse should consider the client's fluid status, blood sugar levels, and potential interactions with medications before instructing the UAP to offer fruit juice.

Choice D reason: This is another incorrect instruction because having the client hold a pillow over the abdomen to cough and deep breathe is not directly related to repositioning the client. While coughing and deep breathing are important for preventing respiratory complications and promoting oxygenation, the nurse should instruct the client to perform these exercises at regular intervals, not only when repositioning.

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Correct Answer is A

Explanation

The correct answer is A. Start collecting the specimen with the next void.

Choice A reason: The 4-hour urine collection for creatinine clearance should start with an empty bladder. The first urine of the day is discarded and the time is noted. All subsequent urine for the next 4 hours, including the first urine the following day, should be collected. If the first sample was put in the urinal hours ago and was not collected, the nurse should start collecting the specimen with the next void.

Choice B reason: Beginning the collection the next day would delay the test and may not be necessary. The test should ideally start after the first urine of the day is discarded.

Choice C reason: Observing the sample for sediment is not typically part of the procedure for a 4-hour urine collection for creatinine clearance. The focus is on collecting all urine for a specified period, not on the physical characteristics of the sample.

Choice D reason: Emptying the sample into the 4-hour container would be incorrect if the sample was the first urine of the day, which should be discarded. The collection should start with the next void.

A. The client's comfort level is increased when the nurse breaks eye contact to type notes into the record. B. Completing the electronic record during an interview is a legal obligation of the examining nurse. C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically. D. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace.

Correct Answer is C

Explanation

Choice A reason: This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B reason: This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C reason: This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D reason: This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

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A client who had surgery 3 days ago is sitting with the head of the bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Correct Answer is A

Explanation

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Correct Answer is C

Explanation

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