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 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.

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Correct Answer is D

Explanation

Choice A rationale:

Allowing the patient to lift the CPM machine onto the bed is not a safe practice. Arthroscopic surgery may result in limited mobility and discomfort for the patient. Lifting heavy equipment could potentially strain the surgical site or lead to injury.

Choice B rationale:

Telling the patient that CPM will not hurt at all is not accurate. While CPM is a passive motion technique aimed at preventing joint stiffness, some discomfort or mild pain may be experienced, especially during the initial sessions. Managing the patient's pain is essential to ensure compliance with the CPM exercises.

Choice C rationale:

Suggesting that the patient does not need to do CPM exercises is incorrect. CPM exercises are often prescribed after joint surgery to prevent joint stiffness, improve circulation, and aid in recovery. Discouraging the patient from participating in these exercises would be detrimental to their postoperative outcome.

Choice D rationale:

Administering an opioid analgesic to the client 30 minutes before initiating CPM exercises is the correct choice. CPM exercises can be uncomfortable for some patients, especially in the initial stages, and providing adequate pain relief before starting the exercises promotes patient comfort and compliance. It helps ensure that the patient can perform the exercises effectively without undue pain, reducing the risk of complications and promoting a successful recovery.

A. Placement of a central venous catheter. B. Insertion of a nasogastric tube. C. Irrigation of a wound with antibiotic solution. D. Administration of an iron injection using Z-track technique.

Correct Answer is A

Explanation

Choice A rationale:

Informed consent is required for invasive procedures that carry significant risks or potential complications. Placement of a central venous catheter is an invasive procedure that involves inserting a catheter into a large vein, often in the neck, chest, or groin. It carries potential risks such as infection, bleeding, and injury to nearby structures. Therefore, informed consent is necessary before performing this procedure.

Choice B rationale:

Insertion of a nasogastric tube is an invasive procedure, but it is generally considered a routine and less risky procedure compared to others. Informed consent is typically not required for nasogastric tube insertion unless there are specific institutional policies or the client lacks decision-making capacity.

Choice C rationale:

Irrigation of a wound with antibiotic solution is a standard nursing procedure, and informed consent is not typically required for wound care unless there are specific circumstances that make it necessary, such as unusual risks or patient-specific considerations.

Choice D rationale:

Administration of an iron injection using Z-track technique is also an invasive procedure, but it is a common and well-established technique for administering intramuscular injections. Informed consent is not routinely required for this procedure unless there are specific institutional policies or the client's condition warrants it.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

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?