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 C

Explanation

Choice A reason: Attaching a syringe to the inflation hub is a later step after sterile field setup and cleansing. Positioning the drape first maintains sterility. Doing this first risks contaminating the sterile field, increasing infection risk, critical to avoid in ensuring safe catheter insertion for clients.

Choice B reason: Cleansing the meatus follows sterile drape placement to maintain a sterile field. Performing cleansing first risks contamination before the field is set, potentially introducing pathogens, critical to prevent in ensuring infection-free catheter insertion, supporting client safety during urinary catheterization procedures.

Choice C reason: Positioning the sterile drape first establishes a sterile field, critical for preventing infection during catheter insertion. This initial step ensures all subsequent actions, like cleansing and insertion, remain sterile, essential for client safety, reducing urinary tract infection risk, and adhering to aseptic technique in catheterization.

Choice D reason: Lubricating the catheter is a later step after sterile field setup and meatal cleansing. Doing this first risks compromising sterility, potentially contaminating the catheter, critical to avoid in ensuring infection prevention, supporting safe insertion, and minimizing complications in clients undergoing urinary catheterization.

A. The nurse wears an N95 respirator when performing client care. B. The nurse ensures the client's room maintains a positive airflow. C. The nurse places the client on airborne precautions. D. The nurse has the client wear a mask for transport to radiology.

Correct Answer is B

Explanation

Choice A reason: Wearing an N95 respirator is appropriate for measles, which spreads via airborne transmission. It protects the nurse from inhaling infectious droplets, aligning with CDC guidelines for airborne precautions, so no intervention is needed for this correct action.

Choice B reason: Positive airflow is incorrect for measles, as it pushes air out, potentially spreading infectious droplets. Negative pressure rooms are required to contain airborne pathogens, so the charge nurse should intervene to correct this error, making it the right choice.

Choice C reason: Placing the client on airborne precautions is correct for measles, a highly contagious airborne disease. This includes negative pressure rooms and N95 respirators, aligning with infection control standards, so no intervention is needed for this appropriate action.

Choice D reason: Having the client wear a mask during transport reduces droplet spread, a standard practice for airborne diseases like measles. It protects others in shared spaces, so no intervention is needed, as this action aligns with infection control protocols.

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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?

Nursing Test Bank

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