A nurse is reviewing documentation procedures with a newly licensed nurse. Which of the following information should the nurse include?

Document care that was omitted due to a client's condition or refusal.

Collaborate with staff members to develop a list of unit-specific abbreviations.

Record subjective interpretations of the client's condition.

Document interventions based on priority instead of time.

Answer and Explanation

The Correct Answer is A

A. Document care that was omitted due to a client's condition or refusal: Accurate documentation should include any interventions that were not performed, along with the reason. This provides a complete record for legal, ethical, and continuity-of-care purposes and ensures transparency in nursing practice.

B. Collaborate with staff members to develop a list of unit-specific abbreviations: Standardized documentation requires the use of approved, universally recognized abbreviations to avoid misinterpretation. Creating unit-specific abbreviations can lead to confusion, errors, and compromised patient safety.

C. Record subjective interpretations of the client's condition: Documentation should focus on objective, factual observations and the client’s reported symptoms rather than the nurse’s personal opinions or interpretations. Subjective interpretations can introduce bias and are not considered professional documentation.

D. Document interventions based on priority instead of time: Interventions should be recorded in chronological order, noting the exact time of care. Prioritizing documentation by importance rather than time can result in incomplete or inaccurate records, compromising continuity of care and legal accuracy.

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Correct Answer is B

Explanation

A. "Maintain your elbow flexed at a 90-degree angle.": When fitted properly, a cane should allow for slight elbow flexion of about 20 to 30 degrees, not 90 degrees. Excessive flexion increases upper extremity fatigue and reduces mechanical advantage, making ambulation less efficient and potentially increasing joint strain.

B. "Keep the cane on the stronger side of the body.": A cane is held on the stronger side to widen the base of support and reduce weight-bearing stress on the weaker or more painful limb. This positioning promotes a more natural gait pattern and decreases joint loading on the affected side, which is especially important in rheumatoid arthritis.

C. "Place the cane forward 5 to 10 cm (2 to 4 in).": The cane is typically advanced approximately 15 to 25 cm (6 to 10 in) forward in coordination with the weaker leg. Advancing it only 2 to 4 inches does not provide adequate forward support or stability during the gait cycle.

D. "Move the stronger leg forward first.": The correct sequence is to move the cane and the weaker leg forward together, followed by advancing the stronger leg. Moving the stronger leg first would shift weight onto the weaker extremity without support, increasing discomfort and fall risk.

A. Sinus tachycardia rate 104/min B. Two premature ventricular contractions per minute C. First degree heart block D. A new onset of atrial fibrillation

Correct Answer is D

Explanation

A. Sinus tachycardia rate 104/min: Mild sinus tachycardia may occur in response to pain, anxiety, or hypovolemia and is usually not immediately life-threatening. While it should be monitored, it does not require urgent reporting unless it worsens or is accompanied by other concerning signs.

B. Two premature ventricular contractions per minute: Occasional PVCs can be benign, especially in a post-MI patient, and may not require immediate intervention. Frequent or paired PVCs, or those occurring in runs, are more concerning for ventricular arrhythmias.

C. First degree heart block: This is characterized by a prolonged PR interval but generally does not compromise cardiac output. It is often stable and can be monitored rather than reported as an urgent finding.

D. A new onset of atrial fibrillation: New-onset atrial fibrillation following a myocardial infarction increases the risk of decreased cardiac output, thromboembolism, and hemodynamic instability. This arrhythmia requires immediate notification of the provider for assessment and initiation of appropriate interventions such as rate or rhythm control and anticoagulation.

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A nurse is reviewing documentation procedures with a newly licensed nurse. Which of the following information should the nurse include?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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