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 C
Explanation
Dementia is characterized by progressive memory impairment, including difficulty remembering recent events, names, and familiar faces. This memory loss can significantly impact the client's ability to perform daily tasks independently.
While dementia is typically a chronic and progressive condition, it is not uncommon for individuals with dementia to experience acute episodes of confusion, often referred to as "sundowning." These episodes tend to occur in the late afternoon or evening and can involve increased agitation, restlessness, and disorientation.
Illusions are perceptual distortions where a person misinterprets real sensory stimuli. In dementia, individuals may experience illusions, such as mistaking a coat hanging on a door for a person or misinterpreting shadows as threatening figures.
Catatonia, characterized by immobility and unresponsiveness, is not typically associated with dementia. It is more commonly seen in conditions such as schizophrenia or certain neurological disorders.
Correct Answer is C
Explanation
Nitroglycerin is a common medication used to relieve chest pain associated with angina. However, if the client is experiencing ongoing chest pain, it is important to follow the prescribed instructions for nitroglycerin administration, which may involve taking additional doses if needed, as instructed by the healthcare provider. Calling the provider after taking one dose may not address ongoing chest pain adequately.
This action, known as the Valsalva maneuver, is not recommended for managing chest pain associated with stable angina. The Valsalva maneuver involves forcibly exhaling while keeping the mouth and nose closed, which can temporarily decrease blood flow to the heart and may exacerbate chest pain.
Chewing two aspirin tablets is recommended for acute myocardial infarction to inhibit platelet aggregation, but in stable angina the immediate priority is rest and nitroglycerin.
I will stop what I am doing and lie down.” This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.
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