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
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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Related Questions
Correct Answer is B
Explanation
A. Inserting a straight urinary catheter for a client:
Inserting a urinary catheter involves a sterile procedure and requires the specialized skills of a licensed nurse. This task should not be delegated to assistive personnel.
B. Performing perineal care for a client who has an indwelling urinary catheter.
Delegating tasks should align with the education, training, and scope of practice of the assistive personnel. Performing perineal care for a client with an indwelling urinary catheter is a task that can be appropriately delegated to assistive personnel. This task involves basic hygiene and does not require the advanced skills or knowledge of a licensed nurse.
C. Showing a client how to use an incentive spirometer:
Educational tasks, such as demonstrating how to use an incentive spirometer, require knowledge and understanding of the device, as well as the ability to assess and respond to the client's needs. This task is best performed by a licensed nurse.
D. Increasing oxygen flow for a client who has a nasal cannula:
Adjusting oxygen flow involves assessing the client's condition and making decisions based on the client's oxygenation needs. This task requires the clinical judgment of a licensed nurse and should not be delegated to assistive personnel.
Correct Answer is C
Explanation
A. Beneficence:
Beneficence is the ethical principle of doing good or promoting the well-being of the patient. In this scenario, the nurse is respecting the client's autonomy rather than actively promoting a specific course of action.
B. Fidelity:
Fidelity refers to the principle of being faithful or keeping promises. While being truthful and honest with the client is important, the nurse's response is primarily addressing the client's autonomy.
C. Autonomy:
This is the correct answer. Autonomy is the ethical principle that emphasizes the individual's right to make decisions about their own care, including the right to refuse treatment. The nurse's response acknowledges and respects the client's autonomy in deciding to discontinue enteral feedings.
D. Justice:
Justice pertains to fairness and equitable distribution of resources. It is not the primary ethical principle being demonstrated in this scenario, as the focus is on the individual's right to make a decision about their own care.
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