A client who has been hospitalized for two weeks tells the nurse that he wants to go home today because he feels fine now and does not need any more treatment or tests done on him at this time.

The nurse knows that this client is scheduled for a cardiac catheterization tomorrow morning and that his discharge date is not yet determined by his physician.

Which of the following actions should the nurse take first?

Inform the client that he cannot leave without a physician’s order.

Explain the purpose and benefits of the cardiac catheterization to the client.

Assess the client’s understanding and readiness for discharge.

Notify the physician and the charge nurse about the client’s request.

Answer and Explanation

The Correct Answer is C

Assess the client’s understanding and readiness for discharge.

This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.

The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.

Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.

The nurse should not threaten or coerce the client to stay in the hospital against his will.

Choice B is wrong because it is not the priority at this time.

The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.

Choice D is wrong because it is not the first action that the nurse should take.

The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.

A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels. It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.

Some of the benefits of cardiac catheterization are:.

• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.

• It can help determine the best treatment plan for the client based on his or her specific condition and needs.

• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.

• It can reduce the need for more invasive surgery or repeated hospitalizations.

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Correct Answer is ["A","B","D","E"]

Explanation

The nurse should use the following abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min:.

• O2: This stands for oxygen and indicates the type of gas being delivered to the patient.

• NC: This stands for nasal cannula and indicates the device used to deliver oxygen to the patient.

• SpO2: This stands for peripheral oxygen saturation and indicates the percentage of hemoglobin that is saturated with oxygen in the blood.

It is measured by a pulse oximeter attached to the patient’s finger or earlobe.

• RR: This stands for respiratory rate and indicates the number of breaths per minute that the patient takes.

It is an important vital sign to monitor in patients with respiratory conditions.

Choice C is wrong because LPM is not an accepted abbreviation for oxygen therapy.LPM stands for liters per minute and indicates the flow rate of oxygen being delivered to the patient.However, it should not be abbreviated as LPM, but written out in full or as L/min.This is to avoid confusion with other abbreviations such as lpm (lowercase L) which stands for light per minute, a unit of luminous flux.

Normal ranges for SpO2 and RR vary depending on the age, health status and activity level of the patient, but generally they are:.

• SpO2: 95% to 100% for healthy adults.

Lower values may indicate hypoxemia (low blood oxygen level) or other conditions affecting oxygen delivery or uptake in the body.

• RR: 12 to 20 breaths per minute for healthy adults.

Higher or lower values may indicate respiratory distress, infection, pain, anxiety or other conditions affecting breathing.

A. It highlights the client’s concerns and strengths. B. It reduces redundancy and duplication of data. C. It facilitates communication among health care team members. D. It incorporates nursing diagnoses and care plans. E. It provides a chronological record of events.

Correct Answer is ["A","B","C"]

Explanation

Focus charting is a method of organizing health information in an individual’s record that centers on the patient’s concerns and strengths.It uses a three-column format to document the data, action and response (DAR) of each focus.

The advantages of using focus charting are:.

• It highlights the client’s concerns and strengths, which makes the care more patient-centered and holistic.

• It reduces redundancy and duplication of data, as it avoids repeating information that is already recorded in other forms or flow sheets.

• It facilitates communication among health care team members, as it promotes interdisciplinary documentation and helps organize the information in a concise and precise way.

Choice D is wrong because focus charting does not incorporate nursing diagnoses and care plans, although it is based on the nursing process.Nursing diagnoses and care plans are documented separately or as part of the action category.

Choice E is wrong because focus charting does not provide a chronological record of events, but rather organizes the data by the focus.A chronological record of events can be found in other forms of documentation, such as narrative or SOAP notes.

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Naxlex Comprehensive Predictor Exams

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is using focus charting to document a client’s progress notes. What are the advantages of using focus charting? (Select all that apply.).

Correct Answer is ["A","B","C"]

Explanation

A nurse is documenting an incident report for a medication error that occurred on her unit. Which of the following actions should the nurse take? (Select all that apply.).

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

A nurse is reviewing a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia. The nurse should follow which of the following guidelines when using an EHR system ? (Select all that apply.).

A nurse is using SOAP format to document a client’s progress note. What does SOAP stand for?

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?