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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Correct Answer is D
Explanation
A. Complete medication reconciliation when a client moves to a new room on the same unit:
While it's important to update the client's information when they change rooms, this may not necessitate a full medication reconciliation. Medication reconciliation is typically more comprehensive and involves a thorough review of the client's entire medication regimen.
B. Medication reconciliation should be completed whenever the nurse administers a medication:
While it's important to verify medications before administration, a full medication reconciliation involves a broader review of the client's entire medication history and should not necessarily be done each time a single medication is administered.
C. Medication reconciliation can be delegated to an assistive personnel:
Medication reconciliation is a complex process that involves a thorough review of the client's medication history, and it is generally considered a nursing responsibility. Delegating this task to assistive personnel may compromise accuracy and completeness.
D. Include herbal supplements in the medication reconciliation:
This is the correct answer. Herbal supplements can interact with prescribed medications and may impact the client's overall health. Including them in the medication reconciliation process ensures a comprehensive assessment of the client's medication regimen.
Correct Answer is D
Explanation
"I might have trouble staying on a low-fat diet after my surgery." This statement, while relevant to postoperative care, is not a reason to delay obtaining the signature or notify the provider. The client's ability to adhere to a low-fat diet is a matter for preoperative education and counseling.
"I can resume my normal activities in 1 to 2 weeks." This statement, while reflecting the client's expectations for recovery, is not a reason to delay obtaining the signature or notify the provider. It indicates the client's understanding of the anticipated postoperative timeline.
"I will plan to be in the hospital for 24 hours following my surgery." This statement is incorrect as it relates to the type of surgery being performed (laparoscopic total cholecystectomy). Hospital stays for this procedure are typically shorter, often involving an overnight stay or even less. This discrepancy should be clarified with the provider before obtaining the signature.
"I hope that removing my appendix will make me feel better." This statement is incorrect and indicates a misunderstanding of the procedure. A laparoscopic total cholecystectomy involves the removal of the gallbladder, not the appendix. The nurse should delay obtaining the signature and notify the provider to ensure the client understands the correct procedure and its implications.
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