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 D
Explanation
A.The prescription specifies “four times per day,” which is clear.
B.The medication specified is erythromycin, which is clear
C.The dosage of 500 mg is clearly specified.
D.The route of administration eg. oral, topical is not specified and needs to be clarified to ensure proper administration.
Correct Answer is D
Explanation
Gentamicin is an aminoglycoside antibiotic that is known to have potential ototoxicity, which means it can cause damage to the inner ear and result in hearing loss. It is important for the nurse to monitor the client's hearing during gentamicin therapy and report any changes or symptoms of hearing loss promptly. Other adverse effects of gentamicin may include nephrotoxicity (kidney damage), so monitoring renal function is also essential.
Hypotension, constipation, and slurred speech are not typically associated with gentamicin use. However, it is important for the nurse to monitor the client for any adverse effects and report any concerning symptoms to the healthcare provider.
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