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 D

Explanation

The APN, also known as a nurse practitioner or clinical nurse specialist, has advanced knowledge and expertise in pharmacology and medication management. They are trained to assess medication interactions, evaluate potential risks, and provide guidance to ensure safe and effective medication use.

The other members of the interdisciplinary team listed are not specifically trained to address medication interactions:

Social worker: Social workers focus on addressing psychosocial aspects of care, such as emotional support, counseling, and resource coordination. While they may provide valuable assistance in various areas of the client's care, they typically do not have specialized knowledge in medication interactions.

Patient care technician: Patient care technicians, also known as nursing assistants or certified nursing assistants, provide direct patient care under the supervision of nurses. They do not typically have the training or authority to address medication interactions.
Psychologist: Psychologists specialize in the assessment, diagnosis, and treatment of mental and emotional health concerns. While they may be involved in the client's overall care, including medication management for mental health conditions, their expertise lies primarily in psychological assessment and therapy rather than medication interactions.

A. "You should take the medication on an empty stomach to prevent a headache." B. The headaches should decrease as you get used to the medication." C. "Swallow the tablet whole to minimize your headaches." D. "You can discontinue the medication until the headache goes away!"

Correct Answer is B

Explanation

Headaches are a common side effect of isosorbide dinitrate, especially when initially starting the medication. However, they often improve as the body adjusts to the medication. It is important to reassure the client that the headaches should decrease over time. If the headaches persist or worsen, the client should inform their healthcare provider for further evaluation and possible adjustment of the medication regimen.

The statement about taking the medication on an empty stomach is not relevant to preventing headaches associated with isosorbide dinitrate.

The statement about swallowing the tablet whole does not address the issue of headaches. Chewable isosorbide dinitrate is designed to be chewed or dissolved in the mouth, and swallowing it whole may not provide the intended therapeutic effect.

Discontinuing the medication until the headache goes away is not recommended without consulting the healthcare provider. Abruptly stopping or changing the dose of isosorbide dinitrate can have serious consequences and should only be done under medical supervision.

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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 D

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Correct Answer is B

Explanation

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