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

Colostrum provides many important antibodies that the newborn lacks.

Colostrum is the thick, yellowish fluid produced by the breasts during the early days after giving birth. It is rich in antibodies, immune factors, and other beneficial components that provide important protection and support for the newborn's health. Colostrum is often referred to as "liquid gold" due to its valuable properties. Antibodies present in colostrum help to strengthen the newborn's immune system and provide protection against various infections and diseases.

These antibodies are especially important during the first few days of life when the newborn's own immune system is still developing.

Option B is incorrect because colostrum does not contain a significant amount of iron. Iron is generally obtained from other sources, such as breast milk or iron-fortified formula, to support the newborn's brain development.

Option C is incorrect because although colostrum contains various essential nutrients, it does not provide a significant amount of vitamin K. Vitamin K is typically given to newborns as a separate supplement to prevent vitamin K deficiency bleeding.

Option D is incorrect because colostrum does not act as a diuretic. Its primary role is to provide the newborn with essential nutrients, antibodies, and immune factors to support their overall health and development.

In summary, colostrum is important for the newborn because it provides valuable antibodies that the newborn lacks, helping to strengthen their immune system and protect against infections and diseases.

A. "You can apply counterpressure to your back with each position change." B. "You can splint the incision with a pillow when changing positions." C. "You should change positions as little as possible." D. "You should use patterned-paced breathing when changing positions."

Correct Answer is B

Explanation

Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.
A. "You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.
C. "You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.
D. "You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, they may not be the most effective strategy for managing pain when changing positions post-cesarean.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. Why is colostrum so important for my baby? Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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