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

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

Note whether the client has a living will.

Document the client's vital signs obtained by assistive personnel.

Begin charting with an evaluation of the data.

Answer and Explanation

The Correct Answer is D

A. Chart a summary of the data at the change of the shift - Documenting a summary of data at the change of shift is appropriate for communication among healthcare providers but should not be the first action. It's important to document all relevant admission data promptly and accurately.
B. Note whether the client has a living will - While documenting the client's living will status is important for their care, it's not the first action to take during admission documentation. Immediate assessment and documentation of essential data related to the client's condition and history take priority.
C. Document the client's vital signs obtained by assistive personnel - Documenting vital signs obtained by assistive personnel is appropriate, but it should not be the first action. The nurse should first conduct a comprehensive assessment and document all relevant admission data.
D. Begin charting with an evaluation of the data - This is the most appropriate action. The nurse should start by evaluating and documenting the admission data systematically and comprehensively. This includes the client's chief complaint, medical history, allergies, current medications, vital signs, physical assessment findings, and any other pertinent information. Starting with an evaluation ensures that all relevant data are captured and documented accurately.

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Correct Answer is A

Explanation

A. Veracity: Veracity refers to the ethical principle of truthfulness or honesty. By informing the client about the potential adverse effects of transcranial magnetic stimulation (TMS) and reassuring them that it should not affect their memory, the nurse is demonstrating truthfulness and providing accurate information to the client.
B. Fidelity: Fidelity pertains to the ethical principle of faithfulness or honoring commitments and promises made to clients. While important, fidelity is not directly demonstrated in this scenario.
C. Beneficence: Beneficence involves the ethical principle of doing good or acting in the best interest of the client to promote their well-being. While providing information about the potential adverse effects of TMS is aligned with beneficence, the specific action described in the scenario focuses more on truthfulness (veracity).
D. Autonomy: Autonomy refers to the ethical principle of respecting the client's right to make their own decisions and choices regarding their healthcare. While autonomy is important in healthcare decision-making, it is not directly demonstrated in this scenario, as the nurse is providing information rather than facilitating the client's decision-making process.

A. Lift the traction weights when repositioning the child in bed. B. Have the child rate their level of pain ever-8 hr. C. Monitor the neurovascular status of the child's lower extremities every 12 hr. D. Educate the child's guardians about pin site care prior to discharge.

Correct Answer is D

Explanation

A. Lift the traction weights when repositioning the child in bed.

This action should not be included in the plan of care because lifting the traction weights can interfere with the traction's effectiveness and potentially cause harm or injury to the child. The weights are specifically calibrated to provide the necessary tension for the traction to stabilize the fracture site.

B. Have the child rate their level of pain every 8 hours.

While pain assessment is an essential component of nursing care, the frequency of every 8 hours may not be sufficient, especially for a child in skeletal traction. Pain management should be more frequent and individualized based on the child's needs, which may vary throughout the day.

C. Monitor the neurovascular status of the child's lower extremities every 12 hours.

Neurovascular assessment is crucial for patients in traction to detect any signs of compromised circulation or nerve function. However, every 12 hours may not be frequent enough to promptly identify changes in neurovascular status. More frequent assessments, such as every 1-2 hours initially and then gradually decreasing based on stability, are typically recommended.

D. Educate the child's guardians about pin site care prior to discharge.

This is the correct answer. Educating the child's guardians about pin site care is essential to prevent infection and other complications associated with skeletal traction. Proper care of the pin sites reduces the risk of infection, which can lead to serious complications such as osteomyelitis. Providing education prior to discharge ensures that the guardians are equipped with the necessary knowledge and skills to care for the child at home effectively.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

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