A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit.
Which of the following sources of information should the nurse rely on for accurate information about the client?
The client
Progress note
Medical history
Family information
The Correct Answer is A
A. The client:
The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.
B. Progress note:
Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.
C. Medical history:
The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.
D. Family information:
Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dorsal surface of the foot:
The skin on the dorsal surface of the foot may have more pigmentation, making it potentially more challenging to detect cyanosis in individuals with dark skin.
B. Pinnae of the ears:
The ears may have variable pigmentation, and the presence of hair can affect the visibility of cyanosis. The skin on the pinnae may not be as thin as the skin on the dorsal surface of the hand.
C. Dorsal surface of the hand
When assessing for cyanosis in a client with dark skin, the nurse should examine areas with less pigmentation or areas where the skin is thin. The dorsal surface of the hand is often a suitable site, as it is less pigmented and can show bluish discoloration if cyanosis is present.
D. Conjunctivae:
The conjunctivae (the mucous membranes lining the inner surface of the eyelids and covering the white part of the eyes) are not a reliable site for assessing cyanosis in individuals with dark skin. Mucous membranes may not show cyanosis as prominently as the skin.
Correct Answer is ["B","D","E"]
Explanation
A. Wait 30 min and return to measure the oral temperature:
Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.
B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:
This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.
C. Document that the nurse was unable to measure the client’s temperature:
Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route
D. Determine if the client has eaten or drank within the last 15 minutes:
Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.
E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:
If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.
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