Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

"The documentation satisfies legal standards established by health care organizations and institutions."

"Documentation of the initial assessment becomes the foundation for the entire nursing process."

"Incorrect conclusions may be made without the documentation of the nurse's opinions."

"Health care institutions have established policies regarding documentation of initial assessments."

Answer and Explanation

The Correct Answer is B

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

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Correct Answer is B

Explanation

A. Lithotomy position is used for gynecologic, rectal, or urologic exams and would not be comfortable for a client with low back pain.
B. Dorsal recumbent position is correct because it allows the client to lie on their back with knees bent, reducing strain on the lower back while facilitating assessment of the chest, extremities, and peripheral pulses.
C. Sim’s position is used for rectal examinations or enemas and is not ideal for assessing the chest and extremities.
D. Prone position (lying face down) would exacerbate low back pain and make it difficult to examine the chest and extremities.

A. Wearing gloves before touching the client. B. Using a separate, disposable blood pressure cuff for each client. C. Wearing gloves to palpate the tongue and buccal membranes. D. Wearing a gown, gloves, and mask during assessment.

Correct Answer is C

Explanation

A. Wearing gloves before touching the client is not necessary unless the nurse anticipates contact with bodily fluids, non-intact skin, or mucous membranes.
B. Using a separate, disposable blood pressure cuff is an example of transmission-based precautions, not standard precautions, unless the client has an infection requiring contact precautions.
C. Wearing gloves to palpate the tongue and buccal membranes is correct because standard precautions require gloves when there is potential contact with mucous membranes, which can expose the nurse to infectious agents.
D. Wearing a gown, gloves, and mask is unnecessary unless the client has an infection that requires additional precautions beyond standard precautions.

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Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

Correct Answer is B

Explanation

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

Correct Answer is C

Explanation

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A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

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