A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?

"Client fell out of bed and cut his forehead due to sedative-induced confusion."

"Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

"Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in medical record for further details."

Answer and Explanation

The Correct Answer is C

A. "Client fell out of bed and cut his forehead due to sedative-induced confusion."

This option provides information about the fall and the cause but lacks specific details about the injury, location, or the client's orientation. It is not as detailed or objective as it could be.

B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

This option includes information about the client's position, the presence of blood, and attributes the fall to the failure of the assistive personnel to put up side rails. While it provides some details, it introduces an element of blame and speculation. It's important to stick to factual information in documentation.

C. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

This option provides specific details about the client's position, the nature and location of the injury (laceration), and the client's orientation status. It is concise, objective, and focused on the relevant information.

D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details."

This option includes information about the fall, the injury, and refers to an incident report for further details. While it provides information, it may be more appropriate to include essential details directly in the documentation rather than referring to another document for additional information.

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Correct Answer is B

Explanation

A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.

C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.

A. Apply petroleum jelly around and inside the nares. B. Cleanse the mask or collar with soapy water every other day. C. Make sure the straps on the mask are secure but not too tight. D. Post "no smoking" warning signs at home in a prominent location. E. Check the tops of his ears regularly for skin breakdown.

Correct Answer is ["C","D","E"]

Explanation

Apply petroleum jelly around and inside the nares:

Petroleum jelly is not recommended for use with oxygen therapy. It can be flammable and may increase the risk of fire when in contact with oxygen.

B. Cleanse the mask or collar with soapy water every other day:

While it's important to keep the oxygen equipment clean, using soapy water might not be suitable for all types of oxygen masks or collars. Specific cleaning instructions provided by the supplier or healthcare provider should be followed to ensure proper hygiene and maintenance of the equipment.

C. Make sure the straps on the mask are secure but not too tight:

Proper fitting of the oxygen mask is crucial for comfort and adequate oxygen delivery. The straps should be secure enough to hold the mask in place but not so tight as to cause discomfort or skin irritation.

D. Post "no smoking" warning signs at home in a prominent location:

Oxygen is highly combustible, and smoking near oxygen can lead to fires or explosions. It's crucial to have clear warning signs in the home to prevent smoking in areas where oxygen is used.

E. Check the tops of his ears regularly for skin breakdown:

Prolonged use of oxygen masks or nasal cannulas can cause skin breakdown, particularly around the ears where the tubing or mask straps may rest. Regular checks for any signs of skin breakdown are essential for early detection and prevention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is preparing to administer aspirin 650 mg PO. Available is aspirin 325 mg tablets. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

A nurse is discussing respite care with the caregiver of an older adult client. When the caregiver asks about the purpose of a respite care program, the nurse should reply that it provides which of the following services?

A nurse is caring for a group of clients on a medical surgical unit. Which of the following tasks is unsafe to assign to an assistive personnel (AP)?

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

A nurse is caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?