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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

a. name of the client:Matching the client's name with their identification band or other official records is a crucial step in preventing medication errors and ensuring the right medication is given to the right person.

b.The client's telephone number is not directly relevant to identifying the client for medication administration purposes.

c.Knowing the client's room number is important to confirm the correct location of the client in the acute care setting. This helps ensure that the nurse administers the medications to the correct client. However, the room number alone is not sufficient for accurate client identification. Room numbers may change, and multiple clients may share the same room. Relying on the room number alone can lead to errors.

d.While the client's diagnosis is important for understanding their medical condition and providing appropriate care, it is not specifically required for identifying the client when administering medications.

A. Weight loss B. Diarrhea C. Insomnia D. Diaphoresis

Correct Answer is C

Explanation

Insomnia refers to the difficulty in falling asleep or staying asleep, leading to sleep disturbances. It is a frequently reported symptom during the initial phase of nicotine withdrawal.

While weight loss can be associated with smoking cessation due to changes in metabolism, it is not a direct manifestation of nicotine withdrawal. Similarly, diarrhea is not a commonly reported symptom of nicotine withdrawal.

Diaphoresis, which refers to excessive sweating, can occur in some individuals during nicotine withdrawal, but it is not as commonly observed as insomnia. It is worth noting that different individuals may experience varying symptoms during nicotine withdrawal, and the intensity and duration of these symptoms can also differ.

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A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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