A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

The client requires reinforcement of teaching about the purpose of his medications.

The client is unable to grasp eating utensils.

The client requests to perform ADLS later in the day.

The client tells the nurse he prefers a snack before bedtime.

Answer and Explanation

The Correct Answer is B

This issue indicates a potential difficulty with fine motor skills and may impact the client's ability to feed themselves independently.

It is important for the interprofessional team, including occupational therapy and/or physical therapy, to be aware of this issue and collaborate on appropriate interventions to improve the client's functional abilities and promote independence in activities of daily living (ADLs).

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Correct Answer is D

Explanation

A.Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.

B.Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used.Delaying dressing changes could increase the risk of infection.
C.In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.

D.Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.

A. Provider's progress notes B. Nursing care plan C. Incident report D. Controlled substance inventory record

Correct Answer is C

Explanation

An incident report is a formal document used to report any unexpected or adverse events that occur during patient care. In this case, the administration of an incorrect dosage is an incident that should be documented in the incident report. The incident report serves as a record of the event and helps to ensure that appropriate follow-up actions are taken to prevent similar incidents in the future. It is important to note that an incident report is not part of the client's permanent medical record and is kept separate from other documentation.

The provider's progress notes, nursing care plan, and controlled substance inventory record are not appropriate locations to document this specific incident. The provider's progress notes are typically used to document the client's medical history, examination findings, treatment plans, and progress. The nursing care plan is a document that outlines the client's nursing diagnoses, goals, and interventions. The controlled substance inventory record is used to track and document the dispensing and administration of controlled substances, but it does not typically include incident reporting.

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A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is C

Explanation

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