A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

The client demonstrated proper technique when drawing up 8 units of insulin.

The client stated ‘’I struggle to see those little lines on the syringe’’

The client FBS was 95 mg/dl

The client seems to be more comfortable performing self-administration of insulin.

Answer and Explanation

The Correct Answer is D

Choice D:

The client seems to be more comfortable performing self-administration of insulin: The use of the term “seems” introduces subjectivity, which weakens the clarity and objectivity of the documentation. It’s better to describe specific observations or objective findings. For instance, instead of using “seems,” the nurse could note how the client demonstrated confidence or performed the task with ease, providing concrete evidence of improvement.

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Correct Answer is D

Explanation

A) A client who has heart failure and peripheral edema:
While heart failure and peripheral edema are significant conditions that require medical attention, they are chronic issues that, in most cases, are not immediately life-threatening in an emergency department setting unless there is acute decompensated heart failure or signs of severe fluid overload or respiratory distress.

B) A client who reports urinary burning and a temperature of 29.2° C (102.5°F):
This client is febrile, which suggests an infection, possibly a urinary tract infection (UTI). Although fever and urinary burning are concerning, infection-related fevers generally don't pose an immediate life threat unless there is sepsis or severe systemic involvement. A temperature of 102.5°F is significant, but the client's condition is not as urgent as other life-threatening emergencies like an arrhythmia or severe cardiovascular instability.

C) A client who has cirrhosis of the liver and bruising on their arms:
Bruising in a client with cirrhosis of the liver could indicate bleeding tendencies, which is an important concern. However, unless there is active bleeding or signs of severe liver failure (e.g., confusion, ascites, jaundice), this is not an immediate, life-threatening situation.

D) A client who has a new onset of atrial fibrillation and a heart rate of 152/min:
A new onset of atrial fibrillation (AF) with a heart rate of 152/min is an immediate priority. This is a life-threatening arrhythmia that can lead to decreased cardiac output, risk of stroke, and hemodynamic instability. A heart rate of 152 beats per minute is dangerously high, which could lead to tachycardia-induced cardiomyopathy or cardiogenic shock. Immediate intervention is needed to manage the arrhythmia and prevent further complications.

A. The client is underweight. B. The client takes anticoagulant medications. C. The client has urinary incontinence D. The client has peripheral vascular disease

Correct Answer is B

Explanation

A) The client is underweight:
Being underweight is not directly associated with an increased risk of incisional hematoma formation. However, underweight individuals may have a lower amount of subcutaneous fat, which could affect wound healing. While nutritional status plays a role in recovery after surgery, being underweight does not specifically increase the risk of hematoma formation at
the incision site.

B) The client takes anticoagulant medications:
Taking anticoagulant medications (e.g., warfarin, heparin, or newer anticoagulants like dabigatran) increases the risk of bleeding and the formation of an incisional hematoma. Anticoagulants work by reducing the blood's ability to clot, making it more difficult to stop bleeding after surgery. This increases the likelihood of blood accumulating in the tissue around the incision site, potentially forming a hematoma.

C) The client has urinary incontinence:
Urinary incontinence does not directly increase the risk of incisional hematoma formation. However, it can lead to other complications, such as skin irritation or infection, but it is not a primary risk factor for hematoma formation in the surgical wound. The main concern with urinary incontinence in the perioperative period is ensuring proper skin care to prevent moisture-associated skin damage.

D) The client has peripheral vascular disease:
Peripheral vascular disease (PVD) affects circulation in the extremities, which can impair wound healing due to decreased blood flow. While PVD can contribute to delayed healing and complications like infection, it is not the most significant factor for the formation of incisional hematomas.

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A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?

Correct Answer is D

Explanation

A nurse is reviewing the medical history of a client who is luted for surgery. Which of the following findings places the client at risk for a complication of incisional hematoma forming?

Correct Answer is B

Explanation

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