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 B

Explanation

B. When applying restraints, ensuring that they can be quickly released is essential for maintaining the safety and well-being of the client. This is especially important in cases where restraints are used to prevent harm or injury to the client, as they should only be used as a last resort and for the shortest duration necessary.

A. Checking capillary refill provides valuable information about peripheral perfusion and the adequacy of blood flow to the extremities. However, ensuring the restraints can be released easily is more crucial.

C. While replacing the nasogastric tube may be necessary if it has been removed, it's not the most immediate concern after applying wrist restraints. The priority is to ensure the safety and comfort of the patient with the restraints in place.

D. Reinserting the peripheral IV catheter may be necessary if it has been dislodged. However, it's not the most critical action immediately after applying wrist restraints.

A. Impaired physical mobility. B. Self-care deficit. C. Risk for infection. D. Risk for impaired skin integrity.

Correct Answer is D

Explanation

D. Neuropathy, especially when associated with numbness and tingling in the lower extremities, poses a significant risk for impaired skin integrity. The loss of sensation can lead to decreased awareness of pressure, friction, or trauma to the feet, making the client more susceptible to skin breakdown, ulcers, and injuries.

A. Increasing numbness and tingling in the lower extremities, which primarily suggests neuropathic symptoms rather than impaired mobility.

B. A self-care deficit may arise if the client's neuropathy significantly affects their ability to perform foot care tasks independently. However, self-care deficit becomes a priority concern.

C. Neuropathy can increase the risk of foot injuries due to decreased sensation, which in turn can lead to infections if not promptly addressed. However, while infection is a potential complication, the immediate concern in this scenario is preventing the development of skin breakdown and ulcers.

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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

The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly removed the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take?

Correct Answer is B

Explanation

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is D

Explanation

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