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?

Medication administration record

Standardized care plan

180 record

Client care Kardex

Answer and Explanation

The Correct Answer is D

A. Medication administration record:

The medication administration record (MAR) primarily contains information related to medications, dosages, and administration times. While it provides important details about medications, it may not offer a comprehensive overview of the client's overall care.

B. Standardized care plan:

A standardized care plan typically outlines general care guidelines and interventions for specific conditions. It may provide a structured approach to care but might lack the individualized details needed for a specific client.

C. 180 record:

The term "180 record" does not commonly refer to a standard nursing documentation form. It might be a local or facility-specific term. Without additional information, it's unclear what type of information this form would contain.

D. Client care Kardex:

This is the correct answer. The Client care Kardex, also known as the patient care summary or Kardex, is a document that consolidates key information about a client's care, including diagnoses, treatments, procedures, and other relevant details. It provides a snapshot of the client's current status and facilitates communication among healthcare providers.

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Correct Answer is C

Explanation

A. "The surgeon can obtain informed consent from the client's adult cousin."Informed consent must be obtained from a parent or legal guardian for a minor. An adult cousin does not have the legal authority to provide consent unless they are the legal guardian of the minor, which is not indicated in this scenario.

B. "The surgeon should delay surgery until he can obtain informed consent from a parent."Delaying surgery in an emergency situation could endanger the client's life or health. In such cases, waiting for parental consent is not advisable, and other legal mechanisms, such as implied consent, should be used to proceed with necessary treatment.

C. "The surgeon can proceed with the surgery by invoking implied consent."In emergency situations where the client is a minor and the parents or legal guardians are not available to provide consent, the principle of implied consent allows healthcare providers to perform life-saving procedures without explicit consent. The law recognizes that in emergencies, delaying treatment to obtain consent could result in harm, so the surgeon can proceed with the surgery.

D. "The client's pediatrician can obtain implied consent."The concept of implied consent is not something that can be "obtained" by another healthcare provider. It is a legal principle that allows healthcare providers to act in the best interest of the client during an emergency when consent cannot be obtained. The pediatrician does not have a role in obtaining or invoking implied consent in this context; it is the responsibility of the surgeon performing the emergency procedure.

A. Use an air-assisted device. B. Position the bed in reverse Trendelenburg. C. Elevate the head of bed to a 45° angle. D. Lower the bed close to the ground.

Correct Answer is A

Explanation

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

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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

A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

Correct Answer is C

Explanation

A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Correct Answer is A

Explanation

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