A nurse has just completed assessment charting on the electronic record for an assigned client. An assistive personnel (AP) who just measured the client's vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?

Allow the AP to document the vital signs prior to logging out.

Log out so the AP can log in to document the vital signs.

Offer to chart the vital signs for the AP.

Recommend the AP come back later when the record is available.

Answer and Explanation

The Correct Answer is B

Choice A reason: Allowing the AP to document the vital signs prior to logging out is not a correct action, as it violates the principles of confidentiality and accountability. The nurse should not share their login credentials or allow anyone else to use their electronic record.

Choice B reason: Logging out so the AP can log in to document the vital signs is the correct action, as it ensures that the documentation is accurate, timely, and secure. The nurse should log out of the electronic record after completing their charting and allow the AP to log in using their own credentials.

Choice C reason: Offering to chart the vital signs for the AP is not a correct action, as it delays the documentation and increases the risk of errors. The nurse should not chart the vital signs for the AP, as they are not the ones who obtained them.

Choice D reason: Recommending the AP come back later when the record is available is not a correct action, as it also delays the documentation and reduces the availability of the electronic record. The nurse should not make the AP wait for the record, as it may affect the continuity of care.

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Correct Answer is B

Explanation

Choice A reason: Notifying staff of the increased fall rate is not the first action that the nurse should take, as it does not address the root cause of the problem or the possible solutions. The nurse should inform the staff of the fall rate after conducting a thorough analysis and developing a plan of action.

Choice B reason: Identifying clients who are at risk for falls is the first action that the nurse should take, as it helps to determine the scope and severity of the problem and the factors that contribute to it. The nurse should use a valid and reliable tool to assess the fall risk of each client and document the findings.

Choice C reason: Reviewing current literature regarding client falls is not the first action that the nurse should take, as it does not provide specific information about the facility's situation or the client's needs. The nurse should review the literature after identifying the clients who are at risk for falls and before implementing a fall prevention plan.

Choice D reason: Implementing a fall prevention plan is not the first action that the nurse should take, as it requires evidence-based interventions and evaluation methods that are tailored to the facility's context and the client's characteristics. The nurse should implement a fall prevention plan after reviewing the current literature and obtaining approval from the stakeholders.

A. The client's code status B. The client's vital signs C. The client's name D. A prescribed consultation

Correct Answer is C

Explanation

Choice A reason: The client's code status is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. The code status indicates the level of resuscitation the client wishes to receive in case of a cardiac or respiratory arrest.

Choice B reason: The client's vital signs are not part of the background information, but rather the assessment section of the SBAR Communication tool. The vital signs reflect the client's current condition and response to treatment.

Choice C reason: The client's name is part of the background information, along with the client's age, diagnosis, reason for admission, and relevant medical history. The background information provides a brief overview of the client's situation and helps to identify the client.

Choice D reason: A prescribed consultation is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. A consultation is a referral to another health care professional for further evaluation or management of the client's condition.

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A nurse has just completed assessment charting on the electronic record for an assigned client. An assistive personnel (AP) who just measured the client's vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process?

Correct Answer is B

Explanation

A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR Communication tool. Which of the following information should the nurse include in the background portion of the report?

Correct Answer is C

Explanation

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