A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?
"Complained about having incisional pain.”
"Voided adequate amounts through the shift.”
"Became short of breath when ambulating.”
"Appeared to be sleeping while in bed.”
The Correct Answer is A
The correct answer is choice A: "Complained about having incisional pain."
Choice A rationale:
Documenting a client's complaints about pain, especially incisional pain, is crucial in an electronic health record. Pain assessment and management are essential aspects of client care, and including this information helps to track the client's pain level, the effectiveness of pain interventions, and any changes in their condition over time.
Choice B rationale:
While it's important to monitor fluid intake and output, stating that the client "Voided adequate amounts through the shift" might be relevant to the client's overall condition but lacks specific information. It doesn't address the reason for the assessment, and the focus should be on the client's immediate care needs and responses.
Choice C rationale:
Noting that the client "Became short of breath when ambulating" is significant for documenting any potential signs of respiratory distress during activity. This information provides valuable insights into the client's ability to tolerate physical exertion and might indicate a need for further assessment or interventions.
Choice D rationale:
Documenting that the client "Appeared to be sleeping while in bed" might not offer significant clinical information unless there is a specific reason for noting the client's sleep patterns. Sleep is an important aspect of recovery, but this choice lacks the context needed to make it a priority entry in the documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Three-point.
Choice A rationale:
The four-point gait is used when a client can bear weight on both legs. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. This gait provides maximum stability but is not suitable for non-weight-bearing conditions.
Choice B rationale:
The three-point gait is appropriate for clients who cannot bear weight on one leg. In this gait, both crutches and the affected leg move forward together, followed by the unaffected leg. This allows the client to keep weight off the injured leg while moving.
Choice C rationale:
The two-point gait is used when a client can bear partial weight on both legs. It involves moving one crutch and the opposite leg forward simultaneously, followed by the other crutch and leg. This gait is faster than the four-point gait but still provides some stability.
Choice D rationale:
The swing-through gait is used by clients who have good upper body strength and balance. It involves moving both crutches forward together and then swinging both legs forward past the crutches. This gait is not typically recommended for clients who need to keep weight off one leg.
Correct Answer is ["B","C","D"]
Explanation
The correct answer is choice b. Wash hands after removing gloves, c. Use antimicrobial hand gel after refilling a client’s water pitcher, and d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.
Choice A rationale:
Placing immunocompromised clients in the same room can increase the risk of cross-infection among them. It is better to isolate them or place them in rooms with clients who have similar infection risks.
Choice B rationale:
Washing hands after removing gloves is crucial to prevent the spread of pathogens that might have contaminated the gloves during patient care.
Choice C rationale:
Using antimicrobial hand gel after refilling a client’s water pitcher helps to maintain hand hygiene and prevent the transmission of infections.
Choice D rationale:
Cleaning the stethoscope with an antimicrobial wipe after obtaining vital signs is essential to prevent the transfer of pathogens between patients.
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