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 ["2"]

Explanation

To calculate the dosage of amoxicillin, the nurse needs to divide the prescribed dose by the available dose and multiply by one tablet. In this case, the prescribed dose is 500 mg and the available dose is 250 mg. Therefore, the nurse should administer:

(500 mg / 250 mg) x 1 tablet = 2 tablets

The nurse should document the administration of amoxicillin in the patient's chart and monitor for any adverse reactions or allergies.

A. Client understands the surgical procedure B. Voluntary consent is given C. Client's ability to read the consent form D. Client's ability to pay for the consented surgical procedure E. Disclosure of the treatment is provided

Correct Answer is ["A","B","E"]

Explanation

A. Client understands the surgical procedure:

The client should have a clear understanding of the proposed surgical procedure, its risks, benefits, alternatives, and potential complications.

B. Voluntary consent is given:

The client's consent should be given voluntarily, without coercion or pressure from healthcare providers or others.

C. Client's ability to read the consent form:

While it is helpful for clients to be able to read the consent form, the ability to read the form is not a requirement for valid consent. The information should be explained verbally if the client cannot read.

D. Client's ability to pay for the consented surgical procedure:

The client's ability to pay for the procedure is not a factor in obtaining informed consent. Financial considerations do not affect the validity of the consent.

E. Disclosure of the treatment is provided:

Healthcare providers must disclose information about the proposed treatment, including its nature, purpose, risks, benefits, and potential alternatives, allowing the client to make an informed decision.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amoxicillin 500 mg PO. Available is amoxicillin 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

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 reviewing a client's medication administration record. For which of the following medications should the nurse place the client on fall precautions?

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives?

A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?

As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?