The nurse knows that documentation should record the interventions and the care given to the client.
What is the rationale?

It is a legal record of accountability for protection of the client and the nurse.

It supports confidentiality and privacy and should never.

It provides continuous reference for all care providers to refer to.

it provides a framework for clients rights and records if they are violated.

Answer and Explanation

The Correct Answer is A

It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.

Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.

Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.

Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Formed stool two times per day, every day, for one week. This indicates that bowel training is attaining the desired outcome because it shows regularity and consistency of bowel movements without the use of laxatives or enemas.

Choice B is wrong because soap sud enemas are not recommended for bowel training as they can irritate the bowel and cause fluid and electrolyte imbalance.

Choice C is wrong because continued use of laxatives can inhibit the natural defecation reflexes and cause dependency.

Choice D is wrong because a formed, soft stool at regular intervals without the use of a laxative is a normal defecation pattern, not an indication of fecal incontinence.

A. Swab the collection port of the catheter with an antiseptic swab. Insert a sterile needle and aspirate 3 to 5 mL of urine into the syringe. B. Immediately clamp the catheter tubing. C. Return one hour later and empty 3 to 5 mL of urine from the drainage bag into a sterile specimen container. D. Flush the catheter with 10 mL of sterile water.

Correct Answer is A

Explanation

Insert a sterile needle and aspirate 3 to 5 mL of urine into the syringe. This is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter because it ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

Choice B is wrong because it does not use sterile technique and it does not collect fresh urine. The urine in the drainage bag may have been sitting there for a long time and may not reflect the current condition of the patient’s urinary tract.

Choice C is wrong because it does not use sterile technique and it flushes the catheter with sterile water, which may dilute the urine and alter its composition.

Choice D is wrong because it does not use sterile technique and it collects urine from the drainage bag, which may be contaminated or stale.

View Question and Answer

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

The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which finding, if identified in a client who is being treated for fecal incontinence would indicate that the bowel training is attaining the desired outcome?

Correct Answer is A

Explanation

Which is the most appropriate action when obtaining a sterile urine specimen from an indwelling urinary catheter?

Correct Answer is A

Explanation

Which nursing intervention should be performed before applying client restraints?

Which age-related physiological change puts a client at higher risk for adverse medication complications?

A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?

Which serum laboratory test result should the nurse expect for a client diagnosed with Imbalanced Nutrition: Less than Body Requirements?

Which criterion should a nurse use to determine the proper length of the needle to administer a subcutaneous (subcut) medication?

Which technique is most appropriate for a nurse to use when cleansing a pressure ulcer?

A nurse who serves on an infection control committee is assessing the adequacy of environmental controls against infection. What does the nurse know to be the first line of defense in medical asepsis?

A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing. Which term is the appropriate choice to accurately document this lung sound?

The nurse knows that documentation should record the interventions and the care given to the client.
What is the rationale?