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.
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Related Questions
Correct Answer is D
Explanation
A. Makes reference in the nurses' notes of completing an incident report. Incident reports are internal documents and should not be referenced in the client's medical record.
B. Documents that the provider wrote an inaccurate prescription. Documentation should focus on facts, not subjective judgments. Notify the provider instead.
C. Remains logged in to the charting system throughout the shift. Leaving the system open poses a risk for a breach of confidentiality.
D. Includes quotes from the client. Documenting direct quotes ensures accurate representation of the client's statements.
Correct Answer is A
Explanation
A. "It sounds like you have concerns about the procedure." This therapeutic response acknowledges the client's feelings and encourages further discussion without judgment.
B. "Why have you decided not to have the procedure?" Asking "why" can make the client feel defensive and may hinder communication.
C. "Don't worry. You will adjust to the colostomy quickly." This statement dismisses the client's concerns and does not foster effective communication.
D. "Do you think that's the right decision for you and your family?" This question may pressure the client instead of promoting open dialogue.
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