A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

Client is itching from medication.

Client states, "I started to itch after taking that medication.".

It appears that the client has a rash from the medication.

Rash from medication noted.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Client states, "I started to itch after taking that medication."

Choice A rationale:

"Client is itching from medication." This statement is not a comprehensive description of the situation and lacks specific information. It doesn't provide any context about when the itching occurred or the client's own observation.

Choice B rationale:

"Client states, 'I started to itch after taking that medication.'" This choice is the correct answer because it accurately documents the client's own statement about the itching and the timing in relation to taking the medication. It includes a direct quote, which helps in maintaining accurate and patient-centered documentation.

Choice C rationale:

"It appears that the client has a rash from the medication." This statement includes an assumption and subjective language ("It appears"), which can be misleading in documentation. It's essential to provide factual and objective information in medical records.

Choice D rationale:

"Rash from medication noted." This choice lacks detail and doesn't capture the client's perspective or the timing of the symptom. It's important to include the client's statement and the time frame in which the symptom occurred.

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Correct Answer is B

Explanation

The correct answer is choice B. Remove the cover gown in the client’s room after providing care. This is because Clostridium difficile spores are not effectively killed by alcohol-based hand rubs and can survive on surfaces for a long time. Removing the gown in the client’s room helps to contain any spores that may have settled on the gown, preventing them from being spread to other areas.

Choice A rationale:

Cleaning hands with an alcohol-based hand rub immediately after removing gloves is wrong because C. difficile spores are resistant to alcohol-based hand rubs. The recommended practice is thorough handwashing with soap and water to physically remove the spores from the hands.

Choice C rationale:

Placing the client in a room with negative-pressure airflow is wrong because this measure is used for airborne infections, such as tuberculosis. C. difficile is spread via the fecal-oral route, primarily through contact with contaminated surfaces or hands, not through the air.

Choice D rationale:

Wearing a mask when administering oral medications to the client is wrong because C. difficile is not spread through respiratory droplets. Masks are not necessary unless there is a risk of splash or spray of contaminated material.

A. Sit beside the client. B. Speak slowly and loudly to the client. C. Dim the lights in the client's room. D. Choose a private room for the interview.

Correct Answer is D

Explanation

The correct answer is choice D: Choose a private room for the interview.

Choice D rationale:

Opting for a private room for the interview is essential when interacting with a client who uses a hearing aid. This choice helps minimize background noise and distractions, ensuring effective communication between the nurse and the client. Adequate lighting and minimizing auditory interference are crucial for clients with hearing difficulties.

Choice A rationale:

Sitting beside the client is a considerate approach, but it may not directly address the hearing aid user's needs. The focus should be on creating an optimal environment for communication, which includes minimizing auditory and visual obstacles.

Choice B rationale:

Speaking slowly and loudly to the client is not the most appropriate approach. While speaking clearly and facing the client is recommended, speaking loudly may distort sounds and hinder understanding for clients with hearing aids.

Choice C rationale:

Dimming the lights in the client's room is not necessary for addressing the needs of a client with a hearing aid. Adequate lighting is important for lip-reading and effective communication, especially for clients who rely on visual cues.

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A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Correct Answer is B

Explanation

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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