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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","G"]
Explanation
Choice A rationale:
Blood pressure is a crucial parameter to monitor in a pregnant woman. A significant increase in blood pressure could indicate a condition called preeclampsia, which is characterized by high blood pressure and damage to another organ system, often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby.
Choice B rationale:
While the respiratory rate is an important vital sign, it does not directly indicate a prenatal complication in this context. Normal respiratory rates for an adult range from 12 to 20 breaths per minute. Changes could indicate a respiratory problem but not specifically a prenatal complication.
Choice C rationale:
Gravida/parity is a standard way to denote a woman's reproductive history but does not indicate a prenatal complication. Gravida refers to the number of times a woman has been pregnant, regardless of the outcome, while parity refers to the number of pregnancies carried past 20 weeks, regardless of whether they were born alive or stillborn.
Choice D rationale:
Decreased fetal activity can be a sign of distress in the fetus. It could indicate complications such as poor oxygenation or other conditions that could affect the health of the baby. It's important for pregnant women to monitor their baby's movements daily after 28 weeks.
Choice E rationale:
A severe headache unrelieved by acetaminophen in a pregnant woman could be a sign of preeclampsia, especially when accompanied by other symptoms such as high blood pressure and changes in vision. This should be evaluated immediately.
Choice F rationale:
Urine ketones are usually checked in pregnant women who have symptoms of a condition called ketoacidosis, which is often seen in women with gestational diabetes. However, this condition is not indicated in this scenario.
Choice G rationale:
Protein in the urine is another potential sign of preeclampsia. It's caused by kidney problems resulting from the high blood pressure. In normal conditions, protein should not be present in urine or should be very low.
Correct Answer is B
Explanation
Choice A rationale:
The statement, "You will no longer be infectious once you have completed a course of antibiotics," is incorrect. Genital herpes is a viral infection caused by the herpes simplex virus (HSV) Antibiotics do not treat viral infections, including herpes. Antiviral medications are used for herpes management, but they do not cure the infection. The virus can remain dormant in the body and reactivate.
Choice B rationale:
"You should increase fluid intake to relieve dysuria" is a correct and important piece of advice. Dysuria (painful urination) can be a symptom of genital herpes. Increasing fluid intake helps dilute urine, reducing discomfort during urination.
Choice C rationale:
"You should have the lesions drained as they appear" is incorrect. Lesion drainage is not a standard treatment for genital herpes. Antiviral medications are typically prescribed to manage outbreaks and reduce their duration and severity.
Choice D rationale:
"You should wear nylon underwear until the lesions have healed" is not the recommended guidance. Wearing loose-fitting cotton underwear is generally advised for comfort and to minimize irritation during a herpes outbreak. Nylon underwear may cause friction and discomfort.
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