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 C

Explanation

Choice A rationale:

"Fidelity involves ensuring that we do no harm to the client." - This statement is not an accurate description of fidelity. Fidelity, in ethical terms, primarily refers to keeping promises and being loyal to clients, rather than preventing harm.

Choice B rationale:

"Fidelity involves making sure clients are able to make their own health care decisions." - While this statement relates to ethical principles, it is more closely associated with the principle of autonomy rather than fidelity. Fidelity is about keeping promises and being trustworthy.

Choice C rationale:

"Fidelity involves keeping promises made to clients." - This is the correct answer. Fidelity is the ethical principle that involves keeping commitments, promises, and agreements made to clients. It emphasizes the importance of honesty, trustworthiness, and integrity in the nurse-patient relationship.

Choice D rationale:

"Fidelity involves treating every client with the same level of respect." - While respecting clients is essential in nursing practice, this statement does not directly address the concept of fidelity. Fidelity is more about keeping promises and being loyal to individual clients rather than a uniform approach to all clients.

A. Observe the client during and after meals. B. Suggest that the client assist with meal planning. C. Instruct the client about effective coping strategies. D. Refer the client to a support group for clients who have eating disorders.

Correct Answer is A

Explanation

Choice A rationale:

The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.

Choice B rationale:

Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.

Choice C rationale:

Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.

Choice D rationale:

Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.

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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 C

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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?