A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)

Event/unusual occurrence reports

Physician/nurse practitioner orders

Living will

Vital sign flow records

Proof of residence or deed to their home

Nurses assessments

Answer and Explanation

Correct Answer : B,C,D,F

B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.

C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.

D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.

F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.

A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.

E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.

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Correct Answer is A

Explanation

A. By critically thinking about client care, nurses can assess situations, analyze data, evaluate options, and make informed decisions that contribute to the delivery of high-quality care. Critical thinking helps nurses identify priorities, anticipate potential complications, and adapt care plans based on individual client needs and responses.

B. While critical thinking is important in research and evidence-based practice, its primary role in client care is to ensure that nursing interventions are well-reasoned, evidence-based, and tailored to meet the specific needs of clients. While clients may benefit indirectly from evidence-based care resulting from nursing research, client care primarily focuses on immediate clinical decision-making and management.

C. Critical thinking involves analyzing various aspects of client care, including physiological, psychological, and social phenomena. By critically analyzing these phenomena, nurses can understand underlying issues, identify contributing factors to health conditions, and determine appropriate nursing interventions to promote health and well-being. This process helps nurses make sense of complex client situations and provide holistic care.

D. Critical thinking enables nurses to consider multiple options or strategies for nursing actions. By critically evaluating these options based on client assessment data, evidence-based practice guidelines, and ethical principles, nurses can make informed decisions about the most effective and appropriate interventions for their clients. This ensures that nursing care is individualized and responsive to the unique needs and preferences of each client.

A. pH 7.45, PaCO2 35, HCO3 22 B. pH 7.25. PaCO2 61, HCO3 26 C. pH 7.23. PaCO2 27, HCO3 25 D. pH 7.54, PaCO2 59. HCO3 26

Correct Answer is B

Explanation

B. pH 7.25, PaCO2 61, HCO3 26

pH is decreased (acidosis).

PaCO2 is elevated (61 mmHg), indicating respiratory acidosis (increased CO2 retention). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.

A. pH 7.45, PaCO2 35, HCO3 22

pH is within normal range (7.35-7.45).

PaCO2 is slightly lower than normal (35 mmHg), indicating mild respiratory alkalosis. HCO3 (bicarbonate) is within normal range (22 mEq/L).

C. pH 7.23, PaCO2 27, HCO3 25

pH is decreased (acidosis).

PaCO2 is lower than normal (27 mmHg), indicating respiratory alkalosis (which is unlikely in the context of morphine overdose with hypoventilation).

HCO3 is within normal range (25 mEq/L).

D. pH 7.54, PaCO2 59, HCO3 26

pH is increased (alkalosis).

PaCO2 is elevated (59 mmHg), indicating respiratory acidosis (consistent with hypoventilation). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.

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A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)

Nursing Test Bank

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what is the primary reason for a nurse to critically think about client care?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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