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 D

Explanation

A. Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment. Examples include MRSA, C. difficile, and other multidrug-resistant organisms.
B. Airborne precautions are used for infections transmitted by small droplets that remain suspended in the air and can be inhaled. Examples include tuberculosis (TB), measles, and chickenpox (varicella).
C. Protective environment precautions are typically used for clients with compromised immune systems, such as those undergoing stem cell transplants, to protect them from environmental pathogens.
D. Droplet precautions are used for infections transmitted by large respiratory droplets that can travel up to approximately 3 feet. Examples include bacterial meningitis, influenza, and pertussis. Therefore, the nurse should initiate droplet precautions for the school-age child with bacterial meningitis.

A. "You might feel a bit confused for a few hours after the procedure." B. "You might notice some changes in your-voice after the procedure." C. "You'll wake up about 30 minutes after the procedure." D. "You can expect to feel some pulsation's in your neck during the procedure."

Correct Answer is A

Explanation

A. "You might feel a bit confused for a few hours after the procedure": Confusion is a common side effect of electroconvulsive therapy (ECT) immediately following the procedure. It typically resolves within a few hours as the effects of anesthesia wear off. Providing this information prepares the client for potential post-procedure effects.
B. "You might notice some changes in your voice after the procedure": Changes in voice are not typically associated with ECT. Therefore, this statement is not relevant to the client's education about what to expect during or after the procedure.
C. "You'll wake up about 30 minutes after the procedure": The duration of unconsciousness following ECT can vary from person to person. While clients typically awaken within minutes after the procedure, specifying a time frame of 30 minutes may not accurately reflect individual experiences.
D. "You can expect to feel some pulsations in your neck during the procedure": Feeling pulsations in the neck is not a common sensation experienced during ECT. This statement does not accurately describe the procedure or its associated sensations.

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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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