A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?
Begin charting with an evaluation of the data.
Document the client’s vital signs obtained by an assistive personnel.
Chart a summary of the data at the change of shift.
Note whether the client has a living will.
The Correct Answer is D
Choice A reason: Beginning charting with an evaluation skips the initial step of collecting and documenting raw data, such as health history and vital signs, which is critical for accurate admission records. This approach risks incomplete documentation, potentially leading to misinformed care plans and overlooking advance directives like a living will, essential for patient-centered care.
Choice B reason: Documenting vital signs from assistive personnel is routine but not the priority during admission. Noting a living will is more critical to ensure legal and ethical care preferences are addressed. Relying solely on delegated data risks missing comprehensive admission details, potentially compromising care coordination and patient autonomy in acute settings.
Choice C reason: Charting a summary at shift change is not specific to admission documentation, which requires detailed initial data, including advance directives like a living will. Summarizing later risks delaying critical information, such as legal preferences, potentially leading to care decisions that conflict with the patient’s wishes in acute care scenarios.
Choice D reason: Noting whether the client has a living will is a priority during admission to ensure advance directives are documented, guiding ethical and legal care decisions. This ensures patient autonomy, especially in acute settings where critical decisions arise. Addressing this upfront prevents oversight, aligning care with the client’s wishes and regulatory standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Preeclampsia is not a contraindication for misoprostol; it may be used cautiously for labor induction in such cases under close monitoring. Transverse lie is a contraindication. Assuming preeclampsia contraindicates misoprostol risks unnecessary avoidance, potentially delaying necessary induction, critical for maternal and fetal safety in labor management.
Choice B reason: Transverse fetal lie is a contraindication for misoprostol, as it increases risks of uterine rupture or cord prolapse during labor induction due to improper fetal positioning. Cesarean delivery is preferred. Recognizing this prevents complications, ensuring maternal and fetal safety, critical in labor induction planning for malpresented fetuses.
Choice C reason: Intrauterine growth restriction is not an absolute contraindication for misoprostol; it may be used with caution if induction is indicated. Transverse lie is a clearer contraindication. Assuming restriction contraindicates risks delaying induction, potentially compromising fetal well-being, critical for timely labor management in growth-restricted pregnancies.
Choice D reason: Postterm pregnancy is an indication, not a contraindication, for misoprostol to induce labor and prevent fetal risks. Transverse lie is the contraindication. Assuming postterm contraindicates misoprostol risks delaying necessary induction, increasing risks like stillbirth, critical for ensuring safe delivery in prolonged pregnancies.
Correct Answer is C
Explanation
Choice A reason: Changing a tracheostomy inner cannula is within an RN’s scope, involving routine airway maintenance. It requires sterile technique and training but is a standard nursing procedure, not restricted to advanced practitioners, making it a permissible task.
Choice B reason: Irrigating an external ear canal is within an RN’s scope, used to remove cerumen or debris. It requires proper technique to avoid injury, but RNs are trained for this, making it a standard nursing intervention, not outside their legal scope.
Choice C reason: Inserting a tunneled central venous catheter is outside an RN’s scope, as it requires surgical skills and is performed by physicians or advanced practice providers. RNs may assist or manage catheters post-insertion, but insertion is restricted, making this the correct choice.
Choice D reason: Administering a platelet transfusion is within an RN’s scope, involving monitoring for reactions and following protocols. It is a standard nursing procedure in settings like oncology, not restricted to advanced practitioners, making it a permissible task.
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