A client presents to the clinic for a postoperative follow-up following surgical repair of a fractured radius.

The client reports their adult child prepares two meals a day for them to eat.

The client's weight is 55.9 kg (123 Ib) and height is 175 cm (69 in). What is the client's BMI?

Choice A rationale: Documentation of admission data should occur as soon as possible after the information is obtained. Waiting until the end of the shift to chart a summary increases the risk of forgetting critical details and delays the communication of important findings to the rest of the healthcare team.

Choice B rationale: The Patient Self-Determination Act requires healthcare facilities to ask clients upon admission if they have advance directives, such as a living will or a durable power of attorney for healthcare. This information must be clearly documented in the medical record to ensure the client's end-of-life wishes are respected.

Choice C rationale: The nursing process begins with assessment, not evaluation. Evaluation is the final step where the nurse determines if goals were met. Charting should follow the chronological order of the nursing process: assessment, diagnosis, planning, implementation, and finally, evaluation.

Choice D rationale: Registered nurses are responsible for the initial admission assessment, which includes the first set of vital signs. While assistive personnel can take routine vitals later, the nurse should personally obtain and document the baseline admission data to ensure accuracy and clinical oversight.

Choice A rationale

Digoxin slows the heart rate by inhibiting the sodium-potassium pump, which increases intracellular calcium and enhances myocardial contractility. Tachycardia is an increase in heart rate, which is the opposite of the expected effect of digoxin. Bradycardia is a more common sign of digoxin toxicity.

Choice B rationale

Insomnia is not a recognized or common side effect of digoxin toxicity. The central nervous system effects of digoxin toxicity typically include confusion, fatigue, and lethargy. Digoxin does not directly interfere with the sleep-wake cycle in a way that would cause insomnia.

Choice C rationale

Hearing loss is not a known symptom of digoxin toxicity. The drug's primary effects are on the cardiovascular and gastrointestinal systems, and to a lesser extent, the central nervous system. Auditory disturbances are not a typical finding associated with the toxic effects of digoxin.

Choice D rationale

Digoxin toxicity often affects the central nervous system and sensory organs. The drug can cause visual disturbances such as blurred vision, photophobia, and a characteristic yellow-green halo around objects (xanthopsia), which is an early sign of toxicity. This effect is a result of digoxin's impact on neural pathways