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?

Medication administration record

Standardized care plan

180 record

Client care Kardex

Answer and Explanation

The Correct Answer is D

A. Medication administration record:

The medication administration record (MAR) primarily contains information related to medications, dosages, and administration times. While it provides important details about medications, it may not offer a comprehensive overview of the client's overall care.

B. Standardized care plan:

A standardized care plan typically outlines general care guidelines and interventions for specific conditions. It may provide a structured approach to care but might lack the individualized details needed for a specific client.

C. 180 record:

The term "180 record" does not commonly refer to a standard nursing documentation form. It might be a local or facility-specific term. Without additional information, it's unclear what type of information this form would contain.

D. Client care Kardex:

This is the correct answer. The Client care Kardex, also known as the patient care summary or Kardex, is a document that consolidates key information about a client's care, including diagnoses, treatments, procedures, and other relevant details. It provides a snapshot of the client's current status and facilitates communication among healthcare providers.

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Correct Answer is B

Explanation

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

A. I should wait until I am terminally ill to complete my advance directives." B. "I must name a relative to make decisions for me in my health care proxy." C. I can state in my living will which medical treatments I want done if I am terminally ill." D. "I will make changes to my advance directives if I change my mind about anything." E. I will need to complete a new living will each time I am hospitalized."

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

Explanation

A. "I should wait until I am terminally ill to complete my advance directives."

This statement is incorrect. It is advisable to complete advance directives before a critical or terminal illness occurs to ensure that one's preferences are known and respected in the event of incapacity.

B. "I must name a relative to make decisions for me in my health care proxy."

This statement is incorrect. While naming a relative is a common choice, individuals can choose any competent person as their healthcare proxy, and it does not have to be a family member.

C. "I can state in my living will which medical treatments I want done if I am terminally ill."

This statement is correct. A living will allows individuals to specify the medical treatments they wish to receive or avoid in the event they become terminally ill or incapacitated.

D. "I will make changes to my advance directives if I change my mind about anything."

This statement is correct. Advance directives are not permanent and can be changed or updated if the individual's preferences or circumstances change.

E. "I will need to complete a new living will each time I am hospitalized."

This statement is incorrect. Advance directives, including living wills, are generally not tied to a specific hospitalization. They remain in effect unless the individual chooses to update or change them.

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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 B

Explanation

A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

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

Explanation

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