A nurse has provided care to a client. Which entry is written correctly?
Client is hard to care for and refuses all treatments and medications. Family present.
Left abdominal incision 1 inch in length without redness, drainage, or edema
"Client seems to be in pain and states, 'I feel uncomfortable.""
Status unchanged, doing well
The Correct Answer is B
A. Client is hard to care for and refuses all treatments and medications. Family present: This entry is subjective and judgmental. Phrases like “hard to care for” are opinion-based rather than objective observations. Proper documentation should describe behaviors or refusals factually, e.g., “Client declined morning medications; family present.”
B. Left abdominal incision 1 inch in length without redness, drainage, or edema: This entry is clear, concise, and objective. It documents a specific finding, including location, size, and absence of complications, without using personal opinions or vague terms. This aligns with best practices for medical documentation and provides accurate, clinically relevant information.
C. "Client seems to be in pain and states, 'I feel uncomfortable.'" The phrase “seems to be in pain” is subjective and speculative. Objective documentation should report the client’s own words or quantifiable assessments, such as pain rated on a 0–10 scale. Using tentative language like “seems” reduces clarity and reliability of the record.
D. Status unchanged, doing well: This entry is vague and lacks detail. It does not provide measurable or objective information about the client’s condition, interventions, or response to care, making it insufficient for professional or legal documentation standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage the client to research the procedure online: While providing additional information can be helpful, asking a client to research a complex surgical procedure online may expose them to inaccurate or misleading information. It also does not address the immediate barrier to comprehension during the consent discussion.
B. Provide the client with a pamphlet of the procedures: Pamphlets can supplement understanding, but they are often written at a reading level that may still be difficult for some clients. They are insufficient on their own to ensure informed consent if the client is struggling to follow the real-time conversation and requires verbal clarification.
C. Ask the surgeon to slow the pace and avoid medical jargon: This action directly addresses the client’s difficulty understanding the procedure. Simplifying language, using lay terms, and slowing the explanation ensures the client can comprehend the information necessary to give informed consent. It reflects advocacy for patient comprehension and supports ethical and legal standards in the consent process.
D. Ask the surgeon to repeat the explanation over again: Simply repeating the explanation at the same pace using the same terminology may not improve understanding. Without adjusting the language or providing clarification, the client may remain confused, and informed consent may still not be achieved.
Correct Answer is C
Explanation
A. Hyperchloremia: Hyperchloremia is an elevated serum chloride level, usually caused by dehydration, renal dysfunction, or excessive saline administration. Kayexalate does not bind chloride ions and therefore has no therapeutic effect on this electrolyte imbalance.
B. Hyperphosphatemia: Hyperphosphatemia occurs when serum phosphate levels rise, often due to renal failure or excessive phosphate intake. Sodium polystyrene sulfonate does not bind phosphate ions, so it is not indicated for treating elevated phosphate levels.
C. Hyperkalemia: Kayexalate (sodium polystyrene sulfonate) is a cation-exchange resin that binds potassium ions in the gastrointestinal tract in exchange for sodium. This process facilitates the removal of excess potassium through feces, lowering serum potassium levels and preventing complications such as cardiac arrhythmias associated with hyperkalemia.
D. Hypermagnesemia: Hypermagnesemia is an elevated serum magnesium level, often related to renal insufficiency or excessive magnesium intake. Kayexalate does not remove magnesium from the body and is therefore ineffective in treating this electrolyte disorder.
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