A client who has been hospitalized for two weeks tells the nurse that he wants to go home today because he feels fine now and does not need any more treatment or tests done on him at this time.
The nurse knows that this client is scheduled for a cardiac catheterization tomorrow morning and that his discharge date is not yet determined by his physician.
Which of the following actions should the nurse take first?
Inform the client that he cannot leave without a physician’s order.
Explain the purpose and benefits of the cardiac catheterization to the client.
Assess the client’s understanding and readiness for discharge.
Notify the physician and the charge nurse about the client’s request.
The Correct Answer is C
Assess the client’s understanding and readiness for discharge.
This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.
The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.
Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.
The nurse should not threaten or coerce the client to stay in the hospital against his will.
Choice B is wrong because it is not the priority at this time.
The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.
Choice D is wrong because it is not the first action that the nurse should take.
The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.
A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels. It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.
Some of the benefits of cardiac catheterization are:.
• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.
• It can help determine the best treatment plan for the client based on his or her specific condition and needs.
• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.
• It can reduce the need for more invasive surgery or repeated hospitalizations.
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Related Questions
Correct Answer is D
Explanation
Narrative charting.
This type of documentation is an example of narrative charting because it chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift in a descriptive format.
Some other choices are:.
• Choice A is wrong because SOAP charting is a type of documentation that is organized by four categories: Subjective, Objective, Assessment, and Plan.
It is commonly used in problem-oriented medical records.
• Choice B is wrong because PIE charting is a type of documentation that uses three categories: Problem, Intervention, and Evaluation.
It is based on the nursing process and eliminates the need for a separate care plan.
• Choice C is wrong because Focus charting is a type of documentation that uses three categories: Data, Action, and Response.
It emphasizes the patient’s concerns, problems, or strengths rather than medical diagnoses.
Normal ranges for vital signs and laboratory values may vary depending on the facility and the patient’s condition.
However, some general ranges are:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: 120/80 mmHg or lower.
• Oxygen saturation: 95% or higher.
• Hemoglobin: 12 to 18 g/dL for men, 11 to 16 g/dL for women.
• Hematocrit: 37% to 49% for men, 36% to 46% for women.
• White blood cell count: 4,000 to 11,000 cells/mm3.
• Platelet count: 150,000 to 400,000 cells/mm3.
• Blood glucose: 70 to 110 mg/dL.
Correct Answer is C
Explanation
Medication administration record.
A medication administration record (MAR) is a document that records the medications that have been given to a patient, including the dose, route, time, and nurse’s initials.
A MAR is an essential part of nursing documentation and ensures safe and accurate medication administration.
Choice A is wrong because a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.
A graphic record does not include information about medications.
Choice B is wrong because a daily care record is a document that records the routine care activities that have been performed for a patient, such as hygiene, nutrition, elimination, mobility, and comfort measures.
A daily care record does not include information about medications.
Choice D is wrong because a client teaching record is a document that records the education that has been provided to a patient or family, such as disease process, medications, diet, exercise, self-care, and discharge planning.
A client teaching record does not include information about medication administration.
CBE documentation is a method of charting by exception that allows the nurse to document only those findings that fall outside the standard of care or norms defined by a specific institution.
CBE documentation reduces the amount of time required to document care and eliminates unnecessary or redundant information.
However, CBE documentation does not apply to medication administration, which must be documented accurately and completely for every patient.
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