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 B

Explanation

Choice A rationale:

Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.

Choice B rationale:

Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.

Choice C rationale:

Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.

Choice D rationale:

Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.

A. Children who have erythema infectiosum (fifth disease) require short-term antibiotic therapy. B. Administration of childhood immunizations will prevent exanthem subitum (roseola infantum) C. Restrict fluids for children who have pertussis. D. Isolate children who have varicella until the vesicles have formed crusts.

Correct Answer is D

Explanation

Choice A rationale:

Children who have erythema infectiosum (fifth disease) require short-term antibiotic therapy. Erythema infectiosum, also known as fifth disease, is caused by a virus and does not require antibiotic therapy. It is a self-limiting illness that does not respond to antibiotics.

Choice B rationale:

Administration of childhood immunizations will prevent exanthem subitum (roseola infantum) Exanthem subitum, or roseola infantum, is typically a viral illness and is not prevented by childhood immunizations. It is caused by human herpesvirus 6 (HHV-6) and human herpesvirus 7 (HHV-7)

Choice C rationale:

Restrict fluids for children who have pertussis. Restricting fluids for children with pertussis is not recommended. Pertussis, also known as whooping cough, can cause severe coughing spells, and it is important to ensure that affected children stay well-hydrated. Restricting fluids can lead to dehydration, which can worsen the condition.

Choice D rationale:

Isolate children who have varicella until the vesicles have formed crusts. Isolation of children with varicella (chickenpox) until the vesicles have formed crusts is a standard infection control measure. Varicella is highly contagious, and isolating affected individuals helps prevent the spread of the virus to others. Once the vesicles have crusted over, the risk of transmission is significantly reduced.

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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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A nurse is reviewing the guidelines for documenting client care.
Which of the following actions should the nurse plan to take?