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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation
B. Instruct the client to change positions frequently
Encouraging the client to move around, walk, change positions during labour can help relieve discomfort, promote optimal fetal positioning positions, or use a birthing ball can help alleviate pelvic pain and potentially facilitate the progress of labour.
Applying fundal pressure during contractions in (option A) is not necessary during the latent stage of labour. Fundal pressure is typically used in the active stage of labour to assist with the descent and positioning of the baby's head.
Telling the client to push during contractions in (option C) is not appropriate during the latent stage of labour. Pushing is typically reserved for the second stage of labour when the cervix is fully dilated.
Encouraging the client to soak in a hot bath in (option D) is not recommended during labour, particularly in the hospital setting. Immersion in hot water (e.g., a hot bath) can increase the risk of infection and is generally not recommended until after the birth of the baby
Correct Answer is ["A","B","C","D"]
Explanation
Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.
Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.
Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.
Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.
The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:
Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.
Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.
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