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.
Document information telephoned in by a nurse who left the unit for the day.
Limit documentation to subjective information.
The Correct Answer is A
Choice A rationale:
Avoiding quoting client comments when documenting is essential to maintain privacy and confidentiality. Quoting verbatim client statements may breach confidentiality and compromise the client's trust.
Choice B rationale:
Documenting giving a dose of pain medication just prior to administration is incorrect. Documentation should reflect the time, date, and relevant details of medication administration, including the client's response and any adverse effects.
Choice C rationale:
Documenting information telephoned in by a nurse who left the unit for the day is appropriate, as long as the information is pertinent to the client's care and documented accurately. Timely communication among healthcare providers is crucial for patient safety.
Choice D rationale:
Limiting documentation to subjective information is not advisable. Documentation should include both objective and subjective data to provide a comprehensive picture of the client's condition and care. Objective data includes vital signs, observations, and measurable findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. Notify the charge nurse about the situation.
Choice A rationale: This is the correct answer because the nurse should notify the charge nurse or the provider who is responsible for obtaining informed consent from the client. The nurse cannot obtain informed consent from a client who does not understand the purpose, risks, benefits, and alternatives of the procedure. The nurse should also respect the client’s right to refuse or withdraw consent at any time. By notifying the charge nurse or the provider, the nurse ensures that the client receives adequate information and clarification before giving consent.This is consistent with the ethical and legal principles of informed consent in nursing
Choice B rationale: This is incorrect because the nurse should not ask the client to sign the consent form anyway. This would violate the client’s autonomy and right to make informed decisions about their health. It would also expose the nurse and the provider to legal and ethical consequences for performing a procedure without valid consent. The nurse should ensure that the client understands the information provided and agrees to the procedure voluntarily. Asking the client to sign the consent form anyway would undermine the trust and communication between the client and the healthcare team.
Choice C rationale: This is incorrect because the nurse should not explain to the client that the procedure will help treat his diagnosis. This is not the nurse’s role or responsibility in the process of obtaining informed consent. The nurse should not provide information that is beyond their scope of practice or expertise. The nurse should also not persuade or coerce the client to agree to the procedure. The nurse should refer the client to the provider who can explain the rationale and evidence for the procedure and answer any questions or concerns the client may have.
Choice D rationale: This is incorrect because the nurse should not remind the client about the specifics of the procedure. This is not the nurse’s role or responsibility in the process of obtaining informed consent. The nurse should not repeat or restate information that the provider has already given to the client. The nurse should also not assume that the client has forgotten or misunderstood the information. The nurse should respect the client’s right to ask questions and seek clarification from the provider who can provide accurate and comprehensive information about the procedure.
Correct Answer is C
Explanation
The correct answer is ChoiceC.
Choice A rationale:Restricting fluid intake to 1 L per day is not recommended for a client with a urinary tract infection (UTI). Adequate hydration is essential for flushing out bacteria from the urinary tract and preventing further infections. Therefore, this choice is incorrect.
Choice B rationale:Taking the prescribed antibiotic until manifestations are gone is partially correct. It’s crucial for the client to complete the entire course of antibiotics, even if symptoms improve or disappear before the medication is finished. Stopping antibiotics early can lead to recurrent infections or antibiotic resistance. Therefore, this choice ispartially correct, but the instruction should be clarified to ensure the client understands the importance of completing the full course of antibiotics.
Choice C rationale:Wearing cotton underwear is recommended for clients with a UTI. Cotton is a breathable fabric that can help keep the area around the urethra dry, reducing the likelihood of bacterial growth. Therefore, this choice is correct.
Choice D rationale:Drinking orange juice daily for 3 to 4 weeks is not specifically recommended for a client with a UTI. While vitamin C can help inhibit bacterial growth, orange juice is high in sugar, which can promote bacterial growth. It’s more beneficial to drink water and other unsweetened fluids to help flush out the bacteria from the urinary tract. Therefore, this choice is incorrect.
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