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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Bacterial reactions cause fever and sepsis from contaminated blood, not primarily low-back pain or chest tightness, which suggest hemolytic reaction. Misidentifying risks delaying transfusion cessation, critical for managing hemolytic reactions. Bacterial reactions require antibiotics, while hemolytic reactions need urgent supportive care to prevent renal failure.

Choice B reason: Allergic reactions cause urticaria or itching, not chills, low-back pain, or chest tightness, which indicate acute hemolytic reaction. Assuming allergic risks incorrect treatment like antihistamines, delaying transfusion stoppage, essential for preventing hemoglobinemia or shock in hemolytic reactions, critical for client safety during transfusions.

Choice C reason: Acute hemolytic reaction, due to ABO incompatibility, causes chills, headache, low-back pain, and chest tightness from hemolysis, risking renal failure. Immediate transfusion cessation and supportive care are critical. Recognizing this ensures rapid intervention, preventing severe complications like shock or death, essential for safe blood transfusion management.

Choice D reason: Febrile nonhemolytic reactions cause fever and chills, not low-back pain or chest tightness, which align with hemolytic reaction. Misidentifying risks delaying critical actions like stopping transfusion, potentially worsening hemolysis outcomes. Febrile reactions need antipyretics, while hemolytic reactions require urgent intervention to prevent organ damage.

A. Dizziness. B. Watery stool. C. Abdominal distention. D. Oliguria.

Correct Answer is C

Explanation

Choice A reason: Dizziness is unrelated to paralytic ileus, which involves impaired bowel motility post-surgery, causing distention. Dizziness may indicate hypovolemia or anesthesia effects. Assuming dizziness indicates ileus risks misdiagnosis, delaying interventions like nasogastric suction for ileus, potentially worsening bowel obstruction and client discomfort in postoperative care.

Choice B reason: Watery stool suggests diarrhea, not paralytic ileus, which causes absent bowel sounds and constipation due to motility loss. Misidentifying watery stool as ileus risks overlooking infectious causes, delaying appropriate treatments like antidiarrheals, while neglecting ileus interventions, critical for restoring bowel function post-orthopedic surgery.

Choice C reason: Abdominal distention is a hallmark of paralytic ileus, resulting from postoperative bowel motility cessation, leading to gas and fluid accumulation. Recognizing this guides interventions like bowel rest or decompression, critical for preventing complications like perforation, ensuring timely recovery, and reducing discomfort in clients post-orthopedic surgery.

Choice D reason: Oliguria (low urine output) indicates renal issues, not paralytic ileus, which presents with distention and absent bowel sounds. Assuming oliguria is ileus-related risks missing dehydration or kidney injury, delaying fluid management, while neglecting ileus treatments, critical for addressing postoperative bowel dysfunction and client recovery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of “tightness” in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is C

Explanation

A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

Correct Answer is C

Explanation

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

A nurse is providing discharge teaching to a client who has GERD. Which of the following information should the nurse include?

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client’s bedside?

A nurse is teaching a newly licensed nurse about directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?