A nurse is documenting client care in the nurses' notes and notices that a space was left blank.
Which of the following actions should the nurse take?

Black out the line with a felt-tip pen.

Leave the space as it is within the entry.

Draw a horizontal line through the space and sign at the end of the line.

Place the date at the beginning of the space, followed by double lines.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Blacking out the line with a felt-tip pen is not an appropriate action for correcting a blank space in the nurses' notes. It can make the entry look unprofessional and may not be accepted as a proper correction.

Choice B rationale:

Leaving the space as it is within the entry is not the correct action because it does not address the blank space or provide necessary documentation. Blank spaces in documentation should be corrected appropriately.

Choice C rationale:

Drawing a horizontal line through the space and signing at the end of the line is the correct action. This is a standard practice for correcting blank spaces in documentation. It signifies that the space was intentionally left blank and has been reviewed and approved by the nurse.

Choice D rationale:

Placing the date at the beginning of the space, followed by double lines, is not a standard or recommended method for correcting blank spaces in documentation. It can lead to confusion and may not meet documentation standards.

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Correct Answer is D

Explanation

Choice A rationale:

Identification is a defense mechanism where an individual associates themselves with another person or group. It does not apply to the situation described in the question.

Choice B rationale:

Reaction formation involves expressing the opposite of one's true feelings or desires. It is not the most suitable defense mechanism for the situation where the adolescent blames the teacher for their failure.

Choice C rationale:

Regression refers to reverting to an earlier stage of development in response to stress or conflict. It does not align with the adolescent's statement about their teacher disliking athletes.

Choice D rationale:

Rationalization is the defense mechanism in which a person provides logical or socially acceptable reasons for their behavior, even if these reasons are not accurate. In this case, the adolescent is rationalizing their poor performance by blaming the teacher's bias against athletes. This choice best fits the situation described.

A. Elevates the legs before applying the stockings. B. Measures the client's calf circumference before selecting the stocking size. C. Applies lotion to the client's legs before putting on the stockings. D. Rolls down the stockings from the thigh to the ankle.

Correct Answer is ["A","B"]

Explanation

A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.

B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.

C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.

D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.

So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.

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A nurse is documenting client care in the nurses' notes and notices that a space was left blank.Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who states, "I failed my math exam because the teacher doesn't like athletes." The nurse should identify that the adolescent is using which of the following defense mechanisms?

Correct Answer is D

Explanation

A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

Correct Answer is ["A","B"]

Explanation

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A nurse is documenting client care in the nurses' notes and notices that a space was left blank.
Which of the following actions should the nurse take?