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.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: Quoting client comments when documenting provides accurate and direct information. It ensures the client's exact words are recorded, which is important for clear communication among healthcare providers and for legal documentation.

Choice B rationale: Documenting medication administration should occur immediately after giving the dose, not prior. This ensures accuracy and prevents potential errors or omissions, maintaining the integrity and safety of the client's medical record.

Choice C rationale: Documenting information telephoned in by a nurse who left the unit ensures continuity of care. It accurately records details that may be critical to the client's treatment and care plan, ensuring that all healthcare providers have up-to-date information.

Choice D rationale: Limiting documentation to subjective information is not sufficient. Comprehensive documentation should include both subjective (client's statements) and objective (measurable data) information to provide a complete and accurate picture of the client's condition and care.

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Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Assigning the client to a negative pressure airflow room is crucial as varicella zoster is highly contagious and can be transmitted through airborne droplets. A negative pressure room helps contain the virus and filters the air, reducing the risk of spread to other patients and healthcare personnel.

Choice B rationale: Administering aspirin is contraindicated in clients with varicella zoster due to the risk of Reye's syndrome, especially in children and adolescents. Aspirin should not be given to children or adolescents with viral infections because it can cause serious complications affecting the liver and brain.

Choice C rationale: Having visitors remain at least 0.91 m (3 feet) away from the client is insufficient. Varicella zoster is highly contagious and requires more stringent airborne precautions, including having visitors wear masks and follow proper hygiene protocols to minimize the risk of transmission.

A. Blood pressure B. Hemoglobin C. Platelet count D. Alanine aminotransferase

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Blood pressure: This finding is consistent with preeclampsia, but not HELLP syndrome.Preeclampsia is defined as new-onset hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) after 20 weeks of gestation, with or without proteinuria.HELLP syndrome is a severe form of preeclampsia that involves hemolysis, elevated liver enzymes, and low platelets, but does not necessarily cause hypertension. Hemoglobin: This finding is consistent with HELLP syndrome, but not preeclampsia.

Hemolysis is one of the main features of HELLP syndrome, which causes a decrease in hemoglobin levels.Preeclampsia does not typically affect hemoglobin levels, unless there is significant blood loss or hemodilution.

Platelet count: This finding is consistent with both preeclampsia and HELLP syndrome.Low platelets (thrombocytopenia) are a common complication of preeclampsia, especially in severe cases.They are also a diagnostic criterion for HELLP syndrome, which requires a platelet count of less than 100,000/mm3.

Alanine aminotransferase: This finding is consistent with HELLP syndrome, but not preeclampsia.Elevated liver enzymes are another hallmark of HELLP syndrome, which indicates liver damage and inflammation.Preeclampsia may cause mild elevations of liver enzymes, but not to the same extent as HELLP syndrome.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

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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?