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.”

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

A. "You will need to look to the side when you put the drops in your eye." B. "You should put the drops directly in the center of your eyeball." C. "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." D. "You should avoid pressing on your tear duct after putting the drops in your eye.”

Correct Answer is C

Explanation

The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”

Choice A rationale:

Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.

Choice B rationale:

Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.

Choice C rationale:

Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.

Choice D rationale:

Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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