A nurse is documenting the care of a client in the computer when she is called to another client's room. Which of the following actions should the nurse take?

Log off the computer to attend the client's needs.

Complete the documentation before going to the client's room.

Leave the computer in the hallway.

Minimize the screen while addressing the client's needs.

Answer and Explanation

The Correct Answer is A

A. Log off the computer to attend the client's needs:

Logging off ensures that the client’s health information is protected, maintaining confidentiality and compliance with HIPAA regulations. This prevents unauthorized access to sensitive information when the nurse is away from the computer.

B. Complete the documentation before going to the client's room:

While completing documentation is important, the nurse should prioritize responding to the immediate needs of the client. The nurse can return to complete the documentation afterward.

C. Leave the computer in the hallway:

Leaving the computer unattended in the hallway poses a security risk and compromises the confidentiality of the client's information.

D. Minimize the screen while addressing the client's needs:

Minimizing the screen does not secure the information on the computer. It can still be accessed by others, potentially leading to breaches of client confidentiality.

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Correct Answer is B

Explanation

A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.

B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.

C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.

D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.

A. Flush the tube with 5 mL of water. B. Test the pH of fluid aspirated from the tube. C. Inject air through the tubing and auscultate for gurgling sounds: D. Change the bag and tubing system every 12 hr

Correct Answer is B

Explanation

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

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A nurse is documenting the care of a client in the computer when she is called to another client's room. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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