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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Instructing parents to avoid bringing fresh flowers into the room is not the primary intervention for a child with Clostridium difficile. While it is essential to maintain a clean environment, the most critical action is to implement proper infection control measures.
Choice B rationale:
This is the correct answer. Initiating contact precautions is crucial when caring for a child with Clostridium difficile. This includes using gloves and gowns to prevent the spread of the bacteria to others.
Choice C rationale:
Using a HEPA filtration system in the room is not the first-line intervention for managing Clostridium difficile. While it can help maintain air quality, it does not directly address the transmission of the bacteria.
Choice D rationale:
Using an N95 respirator is not the primary action in caring for a child with Clostridium difficile. Contact precautions, such as gloves and gowns, are more critical to prevent the spread of infection.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B,C"}}
Explanation
Wheezes: This finding may indicate a latex allergy, as wheezing is a sign of respiratory distress caused by an allergic reaction to latex proteins. Wheezes are not typical of malignant hyperthermia or hypovolemic shock.
Muscle rigidity: This finding is a hallmark of malignant hyperthermia, as it reflects the excessive calcium release and muscle contraction triggered by certain anesthetic agents. Muscle rigidity is not a feature of latex allergy or hypovolemic shock.
Urticaria: This finding is a common manifestation of latex allergy, as urticaria (hives) is a type of skin rash caused by an allergic reaction to latex proteins. Urticaria is not associated with malignant hyperthermia or hypovolemic shock.
Hypercapnia: This finding is indicative of malignant hyperthermia, as hypercapnia (high carbon dioxide levels in the blood) is a result of increased metabolism and oxygen consumption due to muscle rigidity and fever. Hypercapnia is not usually seen in latex allergy or hypovolemic shock, unless there is severe respiratory compromise.
Tachycardia: This finding can be present in all three disease processes, as tachycardia (fast heart rate) is a nonspecific response to stress, fever, pain, hypoxia, or hypovolemia. However, tachycardia is more pronounced and persistent in malignant hyperthermia and hypovolemic shock than in latex allergy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.