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.

Limit documentation to subjective information.

Document giving a dose of pain medication just prior to administration.

Document information telephoned in by a nurse who left the unit for the day.

Answer and Explanation

The Correct Answer is A

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.

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Correct Answer is B

Explanation

When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.

The other options listed are also important but should be addressed after the initial assessment and safety measures:

Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.

A. Open the dampers of fireplaces. B. Turn on ceiling fans and air conditioners. C. Cover heat registers with plastic and tape. D. Exit the home as quickly as possible.

Correct Answer is C

Explanation

Correct answer: C

A.Opening the dampers of fireplaces: This instruction is not appropriate during an outdoor chemical disaster. Opening the dampers of fireplaces can allow contaminated air from outside to enter the home, increasing the exposure to hazardous substances. It is best to avoid introducing outdoor air into the home during such incidents.

B. Turning on ceiling fans and air conditioners: This instruction is also not recommended during an outdoor chemical disaster. Turning on fans and air conditioners can potentially circulate contaminated air within the home, leading to increased exposure. It is best to turn off fans and air conditioners during such incidents and focus on evacuating the area.

C. Covering heat registers with plastic and tape: Covering heat registers with plastic and tape would help seal off potential entry points for contaminated air, reducing the risk of indoor contamination.

D.In the case of a nearby outdoor chemical disaster, it is usually safer to stay indoors and seal the home rather than exit, as going outside could increase exposure to the harmful chemicals.

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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 reviewing the guidelines for documenting client care.

Which of the following actions should the nurse plan to take?