A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?
Avoid quoting client comments when documenting.
Document giving a dose of pain medication just prior to administration.
Limit documentation to subjective information.
Document information telephoned in by a nurse who left the unit for the day.
The Correct Answer is A
Quoting client comments verbatim in the documentation should be avoided. Instead, the nurse should summarize or paraphrase the relevant information provided by the client. This helps to maintain confidentiality and professionalism in the documentation process.
Documenting giving a dose of pain medication just prior to administration: Documentation should accurately reflect the timing and administration of medications. It is not appropriate to document giving a dose of medication just prior to administering it, as it would not provide an accurate account of the client's care. The medication administration should be documented after it has been given.
Limiting documentation to subjective information: Documentation should include both objective and subjective information. Objective information refers to measurable and observable data, while subjective information represents the client's thoughts, feelings, and experiences.
Including both types of information provides a comprehensive view of the client's condition and the care provided.
Documenting information telephoned in by a nurse who left the unit for the day: Documentation should only include information that has been directly observed or obtained by the nurse providing care. It is not appropriate to document information telephoned in by a nurse who is not present and available to verify or provide additional details. Each nurse should be responsible for documenting their own observations and actions.
Accurate and comprehensive documentation is crucial for maintaining continuity of care, ensuring effective communication among the healthcare team, and promoting the client's safety and well-being. Nurses should adhere to institutional policies and guidelines regarding documentation practices and prioritize accuracy, confidentiality, and professionalism in their documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Montelukast is a medication commonly used for the maintenance treatment of asthma. It is not used for immediate relief of wheezing or acute symptoms. Instead, it is taken on a scheduled basis to help control and prevent asthma symptoms over time. The recommended dosing regimen for montelukast in children is once daily in the evening.
The statement about giving the medication every 2 hours, if the child is wheezing, is incorrect, as this medication is not meant to be used for immediate relief of symptoms. It is a preventive medication.
The statement about it taking 2 months of scheduled use before the medication is effective is incorrect. While it may take some time for the medication to reach its full effect, improvement in symptoms can often be seen within a few days to weeks of starting treatment.
The statement about stopping the medication if the child is taking a steroid is incorrect. Montelukast can be used in conjunction with other asthma medications, including steroids, as prescribed by the healthcare provider. It is important to follow the prescribed treatment plan and not discontinue any medication without consulting the healthcare provider.
Correct Answer is C
Explanation
When collecting data from a child with pertussis (whooping cough), the nurse should expect the following manifestations:
- Paroxysmal cough: The hallmark symptom of pertussis is a severe, uncontrollable cough that often occurs in bursts (paroxysms) followed by a characteristic "whooping" sound as the child inhales.
- Posttussive vomiting: The coughing spells can be so severe that they may lead to vomiting.
- Inspiratory whoop: As mentioned earlier, during the inhalation phase after a coughing episode, the child may make a distinctive whooping sound.
- Cyanosis: The prolonged coughing episodes can sometimes cause the child's face to turn blue (cyanosis) due to inadequate oxygen intake.
- Fatigue and exhaustion: The frequent and intense coughing episodes can be exhausting for the child, leading to fatigue and sleep disturbances.
Other possible manifestations of pertussis can include a mild fever, runny nose, and sneezing. However, these symptoms are less specific to pertussis and can be seen in other respiratory infections as well.
The manifestations listed in the question (beefy, red tongue; facial erythema; peeling of the hands and feet) are not typically associated with pertussis and may be indicative of other conditions or diseases. It is important to consult a healthcare provider for a proper evaluation and diagnosis.
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