After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Enter the occurrence after the 1400 notes and identify as "late entry".

Request removal initiated by the Health Information Manager.

Create an electronic correction after 1400 notes are officially unlocked.

Make an electronic addendum following the 1400 documentation.

Answer and Explanation

The Correct Answer is A

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Correct Answer is C

Explanation

A. Suctions secretions from the posterior pharynx:

Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration in an unconscious client. This action indicates proper understanding of oral care principles.

B. Tests for a gag reflex before performing oral care:

Testing for a gag reflex before performing oral care is an important safety measure, especially in unconscious clients, to prevent aspiration or airway obstruction. This action indicates proper assessment and consideration of the client's protective reflexes.

C. Places the client in a supine position:

Placing an unconscious client in a supine position during oral care can increase the risk of aspiration, as it may impair the client's ability to manage oral secretions. The preferred position for oral care in unconscious clients is typically a side-lying position to facilitate drainage of oral secretions and reduce the risk of aspiration.

D. Uses an oral airway to keep the teeth apart:

Using an oral airway to keep the teeth apart is not a standard practice for oral care in unconscious clients and may not be necessary. Proper positioning of the client's head and jaw manipulation can often provide adequate access for oral care without the need for an oral airway.

A. Obtaining clarification from a client's healthcare power-of-attorney. B. Completing discharge teaching to a client and family members. C. Reporting a change in a client's condition to the healthcare provider. D. Offering therapeutic support and comfort to a grieving family.

Correct Answer is C

Explanation

A. Obtaining clarification from a client's healthcare power-of-attorney:

While clear communication is important in this scenario, SBAR may not be necessary as the nurse is seeking information rather than providing a detailed report or recommendation.

B. Completing discharge teaching to a client and family members:

SBAR may not be the most suitable format for discharge teaching, as it is primarily used for communication between healthcare providers regarding a patient's condition and care plan. Discharge teaching typically involves providing comprehensive instructions and information in a manner tailored to the needs of the client and family members.

C. Reporting a change in a client's condition to the healthcare provider:

This is the most appropriate scenario for using the SBAR format. When communicating a change in a client's condition to the healthcare provider, the SBAR framework allows the nurse to provide a concise summary of the situation, relevant background information, assessment findings, and recommendations for further action.

D. Offering therapeutic support and comfort to a grieving family:

SBAR communication is not suitable for offering therapeutic support and comfort to a grieving family. This interaction requires empathy, active listening, and emotional support rather than a structured communication format like SBAR.

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After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is C

Explanation

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Correct Answer is C

Explanation

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