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

Choice A rationale:

Elevating the head of the client's bed for 1 hour after the feeding is the correct choice because it helps reduce the risk of aspiration. Elevating the head of the bed at a 30-45 degree angle can promote the flow of enteral feeding solution into the jejunum, reducing the risk of reflux into the stomach and subsequent aspiration.

Choice B rationale:

Administering the feeding solution at a cold temperature is not recommended. Enteral feedings should be given at or near room temperature to prevent discomfort and cramping in the client.

Choice C rationale:

Rotating the jejunostomy tube once per day is not a standard practice. The tube should be secured in place to prevent dislodgement, but routine rotation is not necessary.

Choice D rationale:

Flushing the tube with 90 mL of sterile water before and after the feeding is not necessary for intermittent bolus enteral feedings. Flushing before and after continuous feedings may be required to maintain patency, but for intermittent bolus feedings, it is not a routine practice.

A. "We require informed consent for all routine treatments.” B. "You can sign the informed consent form after the provider explains the pros and cons of the procedure.” C. "We can accept verbal consent unless the surgical procedure is an emergency.” D. "A family member must witness your signature on the informed consent form.”

Correct Answer is B

Explanation

Choice A rationale:

The statement that "we require informed consent for all routine treatments" is not accurate. Informed consent is typically required for procedures and treatments that carry significant risks or require the patient's understanding and agreement. Routine treatments such as taking vital signs or administering routine medications do not typically require informed consent.

Choice B rationale:

The nurse should include in the teaching that the client can sign the informed consent form after the provider explains the pros and cons of the procedure. This statement emphasizes the importance of informed consent, which requires that the patient receives information about the procedure, risks, benefits, and alternatives before providing their consent.

Choice C rationale:

Stating that verbal consent is acceptable unless the surgical procedure is an emergency is not accurate. Informed consent generally requires written documentation, except in true emergencies when obtaining written consent is not possible due to the patient's condition.

Choice D rationale:

The statement that a family member must witness the client's signature on the informed consent form is not a universal requirement for informed consent. While witnesses may be necessary in some cases, it is not a standard requirement for all surgical procedures. The focus should be on ensuring that the client understands the information provided before consenting.

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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

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is about to undergo surgery.Which of the following statements about informed consent should the nurse include in the teaching?

Correct Answer is 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?