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 D

Explanation

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it:

This is a proper practice. Refrigerating the sample after collection helps preserve its integrity and prevents bacterial growth until it can be analyzed.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill:

This is a proper infection control practice. Chlorhexidine is an effective disinfectant, and cleaning the area following a blood spill helps prevent the spread of infectious agents.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster:

This is a proper practice. Alcohol-based antiseptic is effective in killing a broad spectrum of germs, and hand hygiene is crucial, especially after contact with a client who may have an infectious condition.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture:

This is an infection control hazard. Sterile saline irrigation should not be poured onto an open wound before specimen collection, as it can introduce contaminants and interfere with the accuracy of culture results. Specimens should be collected using aseptic technique to avoid contamination.

A. Open windows to allow smoke to escape if a fire occurs. B. Store a fire extinguisher away from the stove in the home. C. Aim the extinguisher nozzle at the top of the flames if a fire occurs. D. Change batteries in home smoke alarms every 2 years.

Correct Answer is B

Explanation

A.Opening windows during a fire can increase airflow, which may actually intensify the flames and spread the fire faster. Instead, clients should close doors to contain the fire and smoke, stay low to the ground to avoid inhaling smoke, and focus on evacuating the home safely.

B.Storing the fire extinguisher away from the stove ensures it remains accessible if a fire breaks out on or near the stove. If a fire occurs, the extinguisher should be in a location that is easy to access but away from the immediate fire source to prevent the person from reaching through flames to retrieve it.

C.The correct technique is to aim the nozzle at the base of the flames, where the fuel source is. This helps to smother the fire more effectively, as aiming at the base cuts off the fuel source, whereas aiming at the top would be less effective.

D.The batteries in smoke alarms should generally be changed every 6-12 months to ensure they are functioning properly. Many recommendations also suggest testing alarms monthly and replacing the entire smoke alarm every 10 years.

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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?

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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