A nurse is accessing computerized data about a client recently transferred to a step-down unit. Which of the following forms should provide the nurse with the most comprehensive client information?
Client care Kardex
Standardized care plan
I&O record
Medication administration record
The Correct Answer is A
A. Client care Kardex: The Kardex provides a concise, comprehensive overview of the client's care needs, treatments, and status.
B. Standardized care plan: These are generalized and do not provide client-specific information.
C. I&O record: This record focuses solely on fluid intake and output and lacks comprehensive client details.
D. Medication administration record: This record provides details about medications but does not offer a complete picture of the client's care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Elevate the head of the client's bed to 45° during meals: The head should be elevated to 90° to reduce the risk of aspiration during meals.
B. Request a speech therapist consult from the provider: Speech therapists can assess swallowing difficulties and recommend appropriate strategies.
C. Instruct the client to tilt their head back when swallowing: This position increases the risk of aspiration by opening the airway during swallowing.
D. Administer liquids to the client using a syringe: Syringe administration can lead to choking or aspiration and is not a standard feeding practice for dysphagia clients.
Correct Answer is D
Explanation
A. Weigh the client every other day. Daily weights are essential for monitoring fluid retention in pulmonary edema.
B. Place the client in a supine position. The client should be placed in a high Fowler's position to improve lung expansion and reduce dyspnea.
C. Encourage the client to ambulate three times per day. Clients with pulmonary edema are often too compromised to ambulate frequently. Rest is initially preferred.
D. Report urine output less than 30 mL/hr. Low urine output may indicate decreased renal perfusion, fluid retention, or worsening heart failure, all of which require prompt reporting.
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