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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. A newborn has respiratory distress and requires oxygen: This is a clinical event requiring immediate intervention but not necessarily an error or unexpected event warranting an incident report.
B. A newborn has an Apgar score of 7 at 5 minutes after birth: An Apgar score of 7 is within a normal range and does not constitute an unusual or reportable incident.
C. A newborn receives erythromycin ophthalmic ointment 4 hours after birth: Erythromycin should be administered within 1 to 2 hours after birth to prevent neonatal eye infections. Delayed administration requires incident reporting.
D. A newborn receives a heel stick on the outer aspect of the heel: This is standard practice to prevent nerve and tissue damage during blood sampling and does not require an incident report.

A. "The client is 2 hours postoperative following a cholecystectomy." B. "The client rates her pain at a 3 on a 0 to 10 pain rating scale." C. "The client has type 2 diabetes mellitus." D. "The client should wear compression stockings."

Correct Answer is B

Explanation

A. "The client is 2 hours postoperative following a cholecystectomy." This belongs in the "B" (Background) section since it provides historical or procedural information.
B. "The client rates her pain at a 3 on a 0 to 10 pain rating scale." This is part of the "A" (Assessment) portion as it involves the nurse's evaluation of the client's current condition.
C. "The client has type 2 diabetes mellitus." This is background information relevant to the client's medical history and should be included in the "B" section.
D. "The client should wear compression stockings." This is part of the "R" (Recommendation) section as it involves future care instructions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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