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.

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Correct Answer is B

Explanation

A client who has been NPO for four days is most at risk to develop skin breakdown. This is because being NPO (nothing by mouth) can lead

to malnutrition and dehydration, which are both risk factors for bedsores. Malnutrition can impair the skin’s ability to heal and resist infection, while dehydration can make the skin dry and fragile.

Choice A is wrong because applying powder after drying the skin can help prevent moisture and friction, which are also risk factors for bedsores.

Choice C is wrong because bathing twice a week may not be frequent enough to keep the skin clean and free of irritants, which can also contribute to bedsores.

Choice D is wrong because hypertension (high blood pressure) does not directly cause bedsores, although it may be associated with other conditions that affect blood circulation and tissue oxygenation.

A. The client has frequent coughing spells. B. The client reports mild abdominal cramps. C. The client has high-pitched bowel sounds. D. The client reports one to two soft bowel movements per day.

Correct Answer is A

Explanation

This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.

Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.

Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.

Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.

They do not indicate a problem with the tube feeding.

Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.

They do not indicate a problem with the tube feeding.

Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.

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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 older adult on bed rest is most at risk to develop skin breakdown? A client who:.

Correct Answer is B

Explanation

Which symptom experienced by a client receiving a continuous enteral feeding via a nasogastric tube requires priority follow-up by the nurse?

Correct Answer is A

Explanation

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A nurse is reviewing a medication reconciliation for an 80-year-old client with renal disease. Which medication should the nurse be most concerned about?

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