A nurse is documenting admission data for a client on an acute care facility.
Which of the following actions should the nurse take?
Document the client's vital signs obtained by an assistive personnel.
Chart a summary of the data at the change of the shift.
Note whether the client has a living will.
Begin charting with an evaluation of the data.
The Correct Answer is A
Choice A rationale:
Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.
Choice B rationale:
Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.
Choice C rationale:
Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.
Choice D rationale:
Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Wire cutters are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Wire cutters are used for cutting wires and may be found in orthopedic or surgical trays, but they are not specifically required for thoracotomy care.
Choice B rationale:
A tracheostomy tray is not necessary for postoperative care following a thoracotomy with chest tube placement. Tracheostomy trays contain supplies for managing a tracheostomy, which is a procedure involving the creation of an opening in the neck to help with breathing. This procedure is not related to thoracotomy care.
Choice C rationale:
Montgomery straps are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Montgomery straps are used to secure dressings or bandages without adhesive tape. They are not typically used in thoracotomy care.
Choice D rationale:
A padded clamp is essential equipment for postoperative care after a thoracotomy with chest tube placement. The clamp is used to temporarily close or occlude the chest tube during transportation or when changing the drainage system. This prevents air from entering the pleural space, maintaining proper suction and preventing complications such as pneumothorax.
Correct Answer is C
Explanation
- A is incorrect because it is an example of self-disclosure, not altruism. Self-disclosure is sharing personal information or feelings with others.
- B is incorrect because it is an example of jealousy, not altruism. Jealousy is feeling threatened or resentful by someone else's success or happiness.
- C is correct because it is an example of altruism, which is helping others without expecting anything in return. Altruism can enhance self-esteem and coping skills for clients who have breast cancer.
- D is incorrect because it is an example of trust, not altruism. Trust is believing that someone is reliable and honest.
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