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 C
Explanation
Choice A reason: Disulfiram is for alcohol deterrence, causing adverse reactions with alcohol, not for treating withdrawal seizures. Diazepam controls seizures. Administering disulfiram risks worsening withdrawal, potentially exacerbating seizures, critical to avoid in ensuring client safety and effective management of alcohol withdrawal in acute settings.
Choice B reason: Naltrexone reduces alcohol cravings post-detoxification, not treating acute withdrawal seizures, managed by diazepam. Using naltrexone risks uncontrolled seizures, delaying stabilization, critical to prevent in managing alcohol withdrawal. Benzodiazepines are standard, ensuring seizure control and safety in clients experiencing acute withdrawal symptoms.
Choice C reason: Diazepam, a benzodiazepine, is the standard treatment for alcohol withdrawal seizures, reducing neuronal excitability and preventing status epilepticus. Administering it ensures rapid seizure control, critical for client safety, stabilizing neurological status, and preventing complications like brain injury in acute alcohol withdrawal management.
Choice D reason: Acamprosate supports abstinence post-withdrawal, not treating acute seizures, managed by diazepam. Using acamprosate risks uncontrolled seizures, delaying critical intervention, potentially leading to injury or death, critical to avoid in ensuring effective seizure management and safety in clients with alcohol withdrawal.
Correct Answer is ["D","E"]
Explanation
Choice A reason: A respiratory rate of 11/min is slightly below normal (12-20/min) but not immediately concerning in a stable elderly client without respiratory distress. It warrants monitoring but does not require urgent follow-up compared to neurological or musculoskeletal symptoms.
Choice B reason: SpO2 > 94% on room air is normal, indicating adequate oxygenation. This finding does not suggest respiratory compromise, so it does not require immediate follow-up, aligning with expected respiratory status in a stable client.
Choice C reason: Clear lung auscultation is a normal finding, indicating no airway obstruction or fluid. It does not suggest respiratory pathology, so it does not require immediate follow-up, reflecting stable pulmonary function in the client’s assessment.
Choice D reason: Worsening forearm pain after a fall suggests potential fracture, compartment syndrome, or nerve injury, especially in an elderly client. This escalating symptom requires immediate imaging and evaluation to prevent complications like tissue damage, making it critical for follow-up.
Choice E reason: Tingling in the right hand indicates possible nerve compression or injury, such as radial nerve damage from a fall. This neurological symptom demands urgent assessment to prevent permanent impairment, making it a priority for immediate follow-up.
Choice F reason: Ability to move fingers is a positive finding, suggesting some preserved motor function. While reassuring, it does not negate the need to address worsening pain and tingling, so it does not require immediate follow-up compared to other symptoms.
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