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 C

Explanation

By acknowledging and validating the client's feelings of fear and concern, the nurse establishes a supportive and empathetic approach. This response helps build trust and rapport with the client, creating an environment where open communication is encouraged. Engaging in further discussion allows the client to express their thoughts and beliefs, which can aid in understanding their perspective and providing appropriate care.

Option A is not the best response as it directly denies the client's belief, which can further escalate their paranoia and potentially damage the therapeutic relationship.

Option B is also not the best response as it challenges the client's belief without providing validation or understanding. It may make the client defensive and reluctant to share their thoughts further.

Option D is not the best response as it focuses on questioning the client's belief without providing support or empathy. It does not address the underlying fear and may not help the client feel heard or understood.

Correct Answer is ["0.25"]

Explanation

To calculate the amount of haloperidol oral concentrate the nurse should administer, we can use

the following equation:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

In this case, the dose is 0.5 mg and the concentration of the haloperidol oral concentrate is 2 mg/mL.

Volume (mL) = 0.5 mg / 2 mg/mL Volume (mL) = 0.25 mL

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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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A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.25"]

Explanation

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