A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?
ADL
SQ
AU
HS
The Correct Answer is A
A) ADL (Activities of Daily Living): This abbreviation is commonly used in healthcare documentation to refer to the routine tasks individuals perform independently for self-care, such as bathing, dressing, grooming, and toileting. Reminding the newly licensed nurse to use the abbreviation ADL ensures clear and concise documentation of the client's functional status and care needs.
B) SQ: While SQ could stand for subcutaneous (as in SQ injection), it's generally recommended to use the full term "subcutaneous" in documentation to avoid confusion or misinterpretation. Using abbreviations like SQ can lead to errors or miscommunication in healthcare settings.
C) AU: This abbreviation typically stands for "each ear" when documenting information related to the ears, such as when administering eardrops or assessing for symptoms. However, similar to SQ, it's preferable to use the full term "each ear" in documentation to ensure clarity and avoid ambiguity.
D) HS: HS commonly stands for "hour of sleep" or "at bedtime" when documenting medication administration times. However, like other abbreviations, it's advisable to use the full term "at bedtime" to prevent misunderstandings or errors related to medication dosing schedules.
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Related Questions
Correct Answer is D
Explanation
A) The client reports insomnia:
Insomnia is a common symptom in Parkinson's disease but may not pose an immediate threat to the client's health or require urgent intervention compared to other symptoms such as difficulty swallowing.
B) The client requires additional help to stand:
While needing assistance to stand is indicative of the progression of Parkinson's disease and may require attention, it is not typically considered a priority over symptoms that directly impact the client's safety and well-being.
C) The client has increased difficulty dressing:
Increased difficulty dressing is a manifestation of Parkinson's disease progression and may impact the client's independence and quality of life. However, it is not as immediately life-threatening as difficulty swallowing.
D) The client has difficulty swallowing:
Difficulty swallowing, or dysphagia, is a serious concern in Parkinson's disease as it can lead to aspiration, malnutrition, dehydration, and respiratory complications such as pneumonia. It poses a significant risk to the client's safety and requires prompt attention to prevent complications. Therefore, it is the priority finding to report at the interprofessional care conference.
Correct Answer is B
Explanation
B) Log the previous user out of the system:
The immediate action the nurse should take is to protect the client's confidentiality by logging out the previous user from the computer system. This ensures that unauthorized individuals do not have access to the client's health information. By taking this step promptly, the nurse mitigates the risk of unauthorized viewing of sensitive information.
A) Complete an incident report:
While completing an incident report is important for documenting the occurrence, it is not the first action the nurse should take. The priority is to address the immediate breach of confidentiality by securing the computer system to prevent further unauthorized access.
C) Report the incident to the charge nurse:
Reporting the incident to the charge nurse is essential, but it should follow the immediate action of logging out the previous user from the system. The charge nurse can then coordinate any necessary follow-up actions and ensure that appropriate measures are taken to prevent similar incidents in the future.
D) Offer to conduct a unit in-service on client confidentiality:
While staff education on client confidentiality is valuable for preventing future breaches, it is not the first action needed in response to the immediate situation. Addressing the current breach takes precedence to protect the client's privacy. Staff education can be considered as a proactive measure after addressing the immediate concern.
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