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A nurse has just completed assessment charging on the electronic record for an assigned client. An assistive personnel who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?

Recommend the AP come back later when the record is available

Log out so the AP can log in to document the vital signs

Offer to chart the vital signs for the AP

Allow the AP to document the vital signs prior to logging out

Answer and Explanation

The Correct Answer is B

a. Recommend the AP come back later when the record is available:

This option delays the documentation process unnecessarily and may inconvenience the AP.

It doesn't address the issue of maintaining patient confidentiality and accurate documentation.

b. Log out so the AP can log in to document the vital signs:

This is the correct choice as it ensures that each individual's documentation is attributed to the correct user.

It maintains patient confidentiality and adheres to HIPAA regulations.

It allows the AP to complete their task efficiently while preserving the integrity of the electronic record.

c. Offer to chart the vital signs for the AP:

This option involves the nurse taking over the responsibility of documenting the vital signs for the AP, which could lead to confusion and potential errors.

It's not the most appropriate solution as it may not be feasible for the nurse to document the vital signs accurately without directly measuring them.

d. Allow the AP to document the vital signs prior to logging out:

Allowing the AP to document vital signs under the nurse's login compromises the integrity of the electronic record and violates HIPAA regulations.

It's not an acceptable practice as it can lead to inaccuracies in the documentation and compromises patient confidentiality.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

a. "I will wear a surgical mask within 3ft of the client":

This statement is correct. Wearing a surgical mask within 3 feet of the client helps prevent the transmission of respiratory droplets from the client to the healthcare provider or others in close proximity.

b. "I will check that the room has a high-efficiency particulate air filtration system":

This statement is not directly related to implementing droplet precautions. While a high-efficiency particulate air (HEPA) filtration system can help improve air quality in a healthcare setting, it is not a standard requirement for implementing droplet precautions.

c. "I will wear an N95 respirator when providing care for the client":

This statement is not accurate for implementing droplet precautions for influenza. N95 respirators are used for airborne precautions, which are indicated for diseases transmitted by smaller droplet nuclei (e.g., tuberculosis). Surgical masks are typically sufficient for preventing the transmission of respiratory droplets during care for clients with influenza.

d. "I will assign the client to a room with positive airflow":

This statement is not appropriate for implementing droplet precautions. Positive airflow rooms are typically used for clients requiring airborne precautions to prevent the spread of infectious agents in the air. In the case of influenza, droplet precautions are sufficient, and assigning the client to a room with standard airflow is appropriate.

A. Providing a 10 min rest period prior to meals B. Elevating the head of the client’s bed to 30 degrees during mealtime C. Instructing the client to place her chin toward her chest when swallowing D. Withholding fluids until the end of the meal

Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

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A nurse has just completed assessment charging on the electronic record for an assigned client. An assistive personnel who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Correct Answer is C

Explanation

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