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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
RSV is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. To prevent the spread of RSV, it is important to implement droplet precautions. These precautions include wearing a mask and ensuring proper hand hygiene when in contact with the preschooler.
This helps minimize the risk of transmitting the virus to other individuals. Requesting an x-ray of the preschooler's neck is not indicated for RSV. RSV primarily affects the respiratory system, and an x-ray of the neck would not provide relevant information for the diagnosis or management of RSV.
Monitoring the preschooler's urine for protein is not specifically related to RSV. Proteinuria is not a typical manifestation or complication of RSV. Monitoring urine for protein is more relevant in conditions such as kidney disease or urinary tract infections.
Administering fluconazole to the preschooler is not indicated for RSV. Fluconazole is an antifungal medication used to treat fungal infections, and it would not be effective against a viral infection like RSV.
Correct Answer is D
Explanation
It is common for school-age children to exhibit magical thinking and believe that their actions or thoughts have the power to cause events, including the illness or death of a loved one. Therefore, it would be expected for the school-age brother of a child with terminal cancer to have thoughts or beliefs that his own behavior is causing his brother's death.
It is important for the nurse to provide age-appropriate education and support to help the brother understand the nature of the illness and address any misconceptions or feelings of guilt.
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