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 D
Explanation
Choice A reason: A long-term care referral is premature for an independent client with type 2 diabetes, as it assumes significant functional decline. Rural clients benefit from accessible care like telehealth to manage chronic conditions, making this intervention less appropriate than supporting independence.
Choice B reason: Adult day care three times weekly is unnecessary for an independent client and may not address diabetes management directly. It is less practical in rural areas with limited access, making telehealth a more feasible and targeted intervention for ongoing care.
Choice C reason: Reviewing assisted living is inappropriate for an independent client managing type 2 diabetes. It overlooks the client’s ability to live autonomously with support like telehealth, which is more suitable for rural settings to maintain independence and manage chronic conditions.
Choice D reason: Telehealth services enable rural clients with type 2 diabetes to access regular monitoring, education, and consultations, overcoming geographic barriers. This supports independent living, enhances glycemic control, and prevents complications, making it the most appropriate intervention for this client’s care plan.
Correct Answer is C
Explanation
Choice A reason: Meningococcal immunizations are recommended for sickle cell anemia to prevent infections due to functional asplenia, not avoided. Reporting headaches is critical. Advising avoidance risks increased infection susceptibility, potentially causing life-threatening sepsis, critical to prevent in children with sickle cell anemia managing care at home.
Choice B reason: Restricting fluid intake is contraindicated in sickle cell anemia; hydration prevents vaso-occlusive crises. Reporting headaches is priority. Advising restriction risks dehydration, triggering crises, pain, or organ damage, critical to avoid in ensuring safe home management and preventing complications in children with sickle cell disease.
Choice C reason: Reporting sudden, persistent headaches is critical in sickle cell anemia, as they may indicate stroke or cerebral vaso-occlusion, requiring urgent evaluation. This instruction ensures early intervention, preventing neurological damage, essential for safe home management, and improving outcomes in children with sickle cell disease at risk for complications.
Choice D reason: Cold compresses may worsen vaso-occlusive pain in sickle cell anemia by constricting vessels; warm compresses are preferred. Reporting headaches is more critical. Advising cold risks exacerbating pain, delaying effective management, critical to avoid in ensuring comfort and preventing crises in home care for sickle cell anemia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.