A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?

Begin charting with an evaluation of the data.

Document the client’s vital signs obtained by an assistive personnel.

Chart a summary of the data at the change of shift.

Note whether the client has a living will.

Answer and Explanation

The Correct Answer is D

Choice A reason: Beginning charting with an evaluation skips the initial step of collecting and documenting raw data, such as health history and vital signs, which is critical for accurate admission records. This approach risks incomplete documentation, potentially leading to misinformed care plans and overlooking advance directives like a living will, essential for patient-centered care.

Choice B reason: Documenting vital signs from assistive personnel is routine but not the priority during admission. Noting a living will is more critical to ensure legal and ethical care preferences are addressed. Relying solely on delegated data risks missing comprehensive admission details, potentially compromising care coordination and patient autonomy in acute settings.

Choice C reason: Charting a summary at shift change is not specific to admission documentation, which requires detailed initial data, including advance directives like a living will. Summarizing later risks delaying critical information, such as legal preferences, potentially leading to care decisions that conflict with the patient’s wishes in acute care scenarios.

Choice D reason: Noting whether the client has a living will is a priority during admission to ensure advance directives are documented, guiding ethical and legal care decisions. This ensures patient autonomy, especially in acute settings where critical decisions arise. Addressing this upfront prevents oversight, aligning care with the client’s wishes and regulatory standards.

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Correct Answer is D

Explanation

Choice A reason: The retainer clip should be at chest level, not the upper abdomen, to secure the harness and prevent injury. An abdominal position risks strap slippage, reducing safety, so this statement reflects incorrect car seat safety understanding.

Choice B reason: Car seats should remain rear-facing until at least age 2, not 1, per AAP guidelines, to protect the neck and spine. Turning forward-facing too early increases injury risk, making this statement incorrect for safe car seat use.

Choice C reason: Shoulder harness straps should be at or below the shoulders in rear-facing seats, not 3 inches above, to ensure proper restraint. This positioning risks poor fit, so the statement indicates a misunderstanding of car seat safety.

Choice D reason: Positioning the newborn at a 45-degree angle in a rear-facing car seat ensures airway patency and spinal alignment, per safety guidelines. This statement correctly reflects proper car seat installation, indicating accurate understanding of newborn car seat safety.

A. The client reports that the restraints are too tight. B. The client is able to calmly follow commands. C. The client has been in the restraints for 4 hours. D. The client can explain the reasons for their behavior.

Correct Answer is B

Explanation

Choice A reason: Reporting tight restraints indicates discomfort, requiring adjustment, not discontinuation, which depends on behavioral safety. Calmly following commands justifies removal. Ignoring tightness risks injury or agitation, delaying safe restraint removal, critical for ethical care and preventing harm in clients with aggressive behavior.

Choice B reason: Calmly following commands indicates the client is no longer a danger, justifying restraint discontinuation per least-restrictive principles. This ensures safety and ethical care, critical for de-escalation, preventing prolonged restraint risks like injury, and supporting client dignity in acute behavioral management situations.

Choice C reason: Four hours in restraints triggers reassessment, not automatic discontinuation, which depends on behavior (e.g., calmly following commands). Assuming time alone justifies removal risks premature release if unsafe, potentially endangering staff or client, critical to avoid in managing aggressive behavior with mechanical restraints.

Choice D reason: Explaining behavior shows insight but doesn’t guarantee safety; calmly following commands is a stronger indicator for restraint removal. Assuming explanation suffices risks premature discontinuation, potentially compromising safety, critical for ensuring restraints are used only until the client is stable and non-threatening in acute settings.

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A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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