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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Wearing a snug-fitting bra continuously for 72 hours supports breasts, reducing milk production and engorgement discomfort during lactation suppression. This non-pharmacological method is effective, critical for client comfort, preventing mastitis, and ensuring successful transition to bottle feeding in postpartum clients choosing not to breastfeed.

Choice B reason: Limiting fluid to 1 liter daily is unsafe and ineffective for lactation suppression; hydration doesn’t significantly affect milk production. This risks dehydration, potentially causing fatigue or urinary issues. Correct teaching avoids this, focusing on supportive measures like a snug bra, critical for safe postpartum care.

Choice C reason: Manually expressing milk stimulates production, counteracting lactation suppression, and risks prolonged engorgement or mastitis. A snug bra is appropriate. Advising expression misguides the client, delaying suppression, critical to avoid for ensuring comfort and successful cessation of lactation in bottle-feeding postpartum clients.

Choice D reason: Moist heat increases blood flow, stimulating milk production, not suppressing lactation; cold packs or snug bras are used instead. Recommending heat risks prolonged engorgement, causing discomfort or infection. Correct teaching avoids this, ensuring effective suppression, critical for postpartum comfort in non-breastfeeding clients.

A. Pour cool water over the client's perineum. B. Tell the client to gently stroke their lower abdomen. C. Instruct the client to lean slightly backward. D. Turn on the faucets in the client's sink.

Correct Answer is D

Explanation

Choice A reason: Pouring cool water over the perineum may cause discomfort or infection risk and is not a standard method to stimulate urination. It does not address psychological or reflex triggers for voiding, making it ineffective for bedpan urination difficulties.

Choice B reason: Stroking the lower abdomen may stimulate bladder contraction but is less effective than auditory cues for triggering the voiding reflex. It is not a primary intervention for bedpan urination issues, making it less appropriate than running water.

Choice C reason: Leaning slightly backward may increase intra-abdominal pressure, hindering bladder emptying. A forward-leaning or upright position is preferred to facilitate urination, so this instruction is counterproductive for helping the client urinate into a bedpan.

Choice D reason: Turning on faucets creates running water sounds, stimulating the voiding reflex via auditory cues, a proven method to aid urination in bedbound clients. This non-invasive approach addresses psychological barriers, making it the correct action for bedpan difficulties.

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A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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