A nurse is completing the initial admission assessment and history for a critical client. Which of the following is the priority action for the nurse to take?
Develop a plan of care for the client
Provide a schedule of visiting hours to the client’s family
Teach the client about his diagnosis
Document the client’s code status
The Correct Answer is D
A. Develop a plan of care for the client:
Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.
B. Provide a schedule of visiting hours to the client’s family:
While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.
C. Teach the client about his diagnosis:
Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.
D. Document the client’s code status
When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.
Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pallor:
Pallor refers to an unusually pale or white skin color. It is often associated with reduced blood flow, anemia, or shock. Pallor is characterized by a lack of the normal rosy color of the skin.
B. Jaundice:
Jaundice is a yellowing of the skin and mucous membranes due to an excess of bilirubin in the blood. It can be associated with liver dysfunction or other conditions affecting the normal breakdown and elimination of bilirubin.
C. Cyanosis:
Cyanosis is a bluish-gray discoloration of the skin and mucous membranes caused by a decrease in oxygen levels in the blood. It can result from various conditions affecting oxygenation, such as respiratory or circulatory problems. In the context of a broken leg, cyanosis on the affected leg could suggest compromised blood flow or oxygenation.
D. Erythema:
Erythema refers to redness of the skin, often due to increased blood flow to the area. It can be a normal response to irritation, injury, or inflammation. Unlike bluish-gray discoloration seen in cyanosis, erythema is characterized by a red appearance.
Correct Answer is C
Explanation
Correct Answer: C
C. The provider was notified.The nurse should document objective facts, such as notifying the provider, in the client’s medical record. This ensures accurate communication about the client's condition and the steps taken after the fall.
Incorrect answers:
A."An incident report was completed."The completion of an incident report should not be documented in the medical record. Incident reports are internal documents used for quality improvement and risk management, and mentioning them in the medical record could make them discoverable in legal proceedings.
B."There were no injuries sustained."While documenting the client’s physical condition is appropriate, stating "no injuries sustained" might be premature or subjective. Instead, the nurse should record specific observations, such as "client denies pain" or "no visible signs of injury noted."
D."An incident report was forwarded to risk management.Referencing the incident report in the medical record is inappropriate. Incident reports are separate from the client’s medical record and should not be mentioned in the documentation.
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