A nurse is accessing computerized data about a client recently transferred to a step-down unit. Which of the following forms should provide the nurse with the most comprehensive client information?

Client care Kardex

Standardized care plan

I&O record

Medication administration record

Answer and Explanation

The Correct Answer is A

A.   Client care Kardex: The Kardex provides a concise, comprehensive overview of the client's care needs, treatments, and status.
B.   Standardized care plan: These are generalized and do not provide client-specific information.
C.   I&O record: This record focuses solely on fluid intake and output and lacks comprehensive client details.
D.   Medication administration record: This record provides details about medications but does not offer a complete picture of the client's care.

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Correct Answer is D

Explanation

A. Showing a client who has a new colostomy how to empty the pouch. Client education requires the clinical knowledge and teaching skills of a nurse.
B. Re-inserting an NG tube for a client who requires gastric decompression. NG tube insertion is a skilled task that requires clinical assessment and monitoring by a nurse.
C. Performing a closed catheter irrigation for a client who is postoperative. Closed catheter irrigation requires sterile technique and clinical judgment, which are nursing responsibilities.
D. Bathing a client who has hemiparesis following a stroke. APs can assist with bathing and hygiene tasks.

A. Place throw rugs on uncarpeted floors in the client's home. B. Ensure the client wears non-skid slippers when walking around the house. C. Encourage an annual review of the medications the client is taking. D. Install a raised toilet seat in the client's bathroom. E. Attach full-length side rails to the client's bed.

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

Explanation

A. Place throw rugs on uncarpeted floors in the client's home. Throw rugs are a tripping hazard and should be removed or secured.
B. Ensure the client wears non-skid slippers when walking around the house: Non-skid slippers provide traction and reduce the risk of slipping.
C. Encourage an annual review of the medications the client is taking. Many medications can cause dizziness or sedation, increasing fall risk, so regular medication reviews are essential.
D. Install a raised toilet seat in the client's bathroom. A raised toilet seat makes it easier for older adults to use the toilet and reduces the risk of falls when standing or sitting.
E. Attach full-length side rails to the client's bed. Full-length side rails can increase the risk of injury if the client attempts to climb over them. Half-rails may be safer.

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A nurse is accessing computerized data about a client recently transferred to a step-down unit. Which of the following forms should provide the nurse with the most comprehensive client information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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

Explanation

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