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

Chart a summary of the data at the change of the shift.

Note whether the client has a living will.

Document the client's vital signs obtained by assistive personnel.

Begin charting with an evaluation of the data.

Answer and Explanation

The Correct Answer is D

A. Chart a summary of the data at the change of the shift - Documenting a summary of data at the change of shift is appropriate for communication among healthcare providers but should not be the first action. It's important to document all relevant admission data promptly and accurately.
B. Note whether the client has a living will - While documenting the client's living will status is important for their care, it's not the first action to take during admission documentation. Immediate assessment and documentation of essential data related to the client's condition and history take priority.
C. Document the client's vital signs obtained by assistive personnel - Documenting vital signs obtained by assistive personnel is appropriate, but it should not be the first action. The nurse should first conduct a comprehensive assessment and document all relevant admission data.
D. Begin charting with an evaluation of the data - This is the most appropriate action. The nurse should start by evaluating and documenting the admission data systematically and comprehensively. This includes the client's chief complaint, medical history, allergies, current medications, vital signs, physical assessment findings, and any other pertinent information. Starting with an evaluation ensures that all relevant data are captured and documented accurately.

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Correct Answer is C

Explanation

A. Peanut butter: Peanut butter is typically thick and sticky, which can pose a choking hazard for individuals with dysphagia, especially if they have difficulty swallowing thicker textures. Therefore, peanut butter is not a suitable recommendation for a client with dysphagia.
B. Crispy rice bar: Crispy rice bars are often dry and crunchy, which can be challenging for individuals with dysphagia to swallow safely. Foods with dry or brittle textures can increase the risk of aspiration or choking, particularly in those with swallowing difficulties.
C. Scrambled eggs: Scrambled eggs are a suitable option for individuals with dysphagia, especially if they are prepared to a soft and moist consistency. Eggs are a good source of protein and can be easily modified to meet the texture requirements of a dysphagia diet. Soft and moist foods are generally safer for individuals with swallowing difficulties.
D. Soda crackers: Soda crackers are dry and crumbly, which can present a choking risk for individuals with dysphagia. Foods with a dry and crumbly texture should be avoided or modified to a safer consistency for individuals with swallowing difficulties. Therefore, soda crackers are not recommended for a client with dysphagia.

A. Lubricate the catheter with water-soluble gel. B. Position the sterile drape leaving the perineum exposed. C. Cleanse the client's meatus with antiseptic solution. D. Attach a prefilled syringe to the catheter inflation hub. E. None F. None

Correct Answer is B

Explanation

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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