The nurse is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

Wait for notification that the system has been rebooted.

Identify information as late entry in the record.

Notify information services department of the situation.

Print electronic medical record (EMR) from backup server.

Answer and Explanation

The Correct Answer is C

C. When the computer documentation system freezes, the first action the nurse should take is to notify the information services department of the situation. This allows the IT professionals to address the issue promptly and work on resolving the problem with the computer system.

A. Waiting for the system to reboot may lead to delays in documenting important patient information and could potentially affect the continuity of care. It's important to address the situation promptly to minimize any disruptions in patient care.

B. If the documentation system is unavailable for an extended period, identifying information as a late entry may be necessary to ensure that it is accurately recorded in the patient's record.

However, this should not be the first action taken, as there may be other immediate steps to address the situation.

D. While having a backup EMR is essential, printing it may not be the immediate solution. The focus should be on resolving the system freeze rather than relying solely on a printed backup.

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Correct Answer is D

Explanation

D. To assess fever patterns accurately in a client with a fever of unknown origin, the nurse should measure the temperature at regular intervals. This helps in identifying trends and patterns in the fever, such as spikes at specific times of the day or consistent elevations. Regular temperature measurements provide valuable information for the healthcare team to diagnose and manage the underlying cause of the fever effectively.

A. Assessing for flushed, warm skin can be indicative of fever, due to vasodilation and skin flushing. While this assessment can provide subjective clues about the presence of fever, it does not provide comprehensive information about fever patterns over time.

B. Different sites may reflect variations in temperature due to local factors or differences in blood flow. However, while varying sites can contribute to a comprehensive assessment of body temperature, it does not specifically address the need to assess fever patterns over time.

C. While circadian rhythms can influence temperature variations, particularly in relation to sleep- wake cycles, documenting circadian rhythms alone does not provide specific information about fever patterns.

A. Observe the client's skin and mucous membranes. B. Palpate the client's pedal pulse volume bilaterally. C. Auscultate the bowel sounds in all four quadrants. D. Determine the elasticity of the client's skin turgor.

Correct Answer is A

Explanation

A. During nasopharyngeal suctioning, the nurse should primarily focus on observing the client's skin and mucous membranes for signs of oxygenation and perfusion. This includes assessing for cyanosis, pallor, or any other signs of inadequate oxygenation.

B. Palpating the client's pedal pulses, which are pulses in the feet, is not directly relevant to nasopharyngeal suctioning. Pedal pulses are typically assessed to evaluate peripheral vascular status and circulation in the lower extremities.

C. Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. Bowel sounds are typically assessed to evaluate gastrointestinal function and motility.

D. Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. Skin turgor is typically assessed to evaluate hydration status, with decreased skin turgor often indicating dehydration.

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The nurse is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is D

Explanation

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is A

Explanation

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