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 ["A","C","D"]
Explanation
Choice A reason: Obtaining vital signs every 4 hours is within the assistive personnel’s scope, ensuring timely monitoring without requiring nursing judgment. Delegating this frees nurses for complex tasks, enhancing efficiency. Proper training ensures accuracy, critical for detecting changes in client status, supporting safe care delivery in busy clinical settings.
Choice B reason: Inserting an NG tube requires nursing skills for assessment and placement verification, not suitable for assistive personnel. Delegating this risks complications like misplacement, potentially causing aspiration or injury, critical to avoid. Nurses must perform this, ensuring safety and accuracy in clients needing enteral feedings.
Choice C reason: Recording intake after meals is an appropriate task for assistive personnel, involving observation and documentation, not clinical judgment. Delegating this supports nutritional monitoring, freeing nurses for higher-level tasks. Training ensures accurate records, critical for assessing fluid and nutritional status in clients across various clinical conditions.
Choice D reason: Transferring a client to physical therapy is within assistive personnel’s scope, involving safe mobility assistance, not clinical decision-making. Delegating this enhances workflow, allowing nurses to focus on complex care. Proper training ensures safety, critical for preventing falls and supporting rehabilitation in clients requiring physical therapy.
Choice E reason: Instructing on incentive spirometer use requires nursing expertise to teach technique and assess understanding, not suitable for assistive personnel. Delegating risks ineffective use, potentially leading to atelectasis. Nurses must provide this education, ensuring proper respiratory care, critical for preventing complications in clients at risk for lung issues.
Correct Answer is D
Explanation
Choice A reason: The retainer clip should be at chest level, not the upper abdomen, to secure the harness and prevent injury. An abdominal position risks strap slippage, reducing safety, so this statement reflects incorrect car seat safety understanding.
Choice B reason: Car seats should remain rear-facing until at least age 2, not 1, per AAP guidelines, to protect the neck and spine. Turning forward-facing too early increases injury risk, making this statement incorrect for safe car seat use.
Choice C reason: Shoulder harness straps should be at or below the shoulders in rear-facing seats, not 3 inches above, to ensure proper restraint. This positioning risks poor fit, so the statement indicates a misunderstanding of car seat safety.
Choice D reason: Positioning the newborn at a 45-degree angle in a rear-facing car seat ensures airway patency and spinal alignment, per safety guidelines. This statement correctly reflects proper car seat installation, indicating accurate understanding of newborn car seat safety.
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