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 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.

A. Place immunocompromised clients in the same room. B. Wash hands after removing gloves. C. Use antimicrobial hand gel after refilling a client's water pitcher. D. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

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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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 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

A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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