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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I will position the shoulder harness straps 3 inches above my baby's shoulders.": The shoulder harness straps should be positioned at or below the baby's shoulders, not above them, to ensure proper restraint in the event of a crash. Placing the straps too high can increase the risk of injury to the baby.
B. "I will position my baby at a 45-degree angle in the car seat.": This statement indicates an understanding of proper car seat positioning for a newborn. Newborns should be positioned at a 45-degree angle in a rear-facing car seat to keep the airway open and prevent head flopping, which can restrict breathing. This angle helps to keep the baby's head from falling forward and blocking the airway.
C. "I will turn the car seat forward-facing when my baby is 1 year old.": It is recommended to keep infants in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age. Turning the car seat forward-facing prematurely increases the risk of injury to the baby's head, neck, and spine in the event of a crash.
D. "I will place the retainer clip on my baby's upper abdomen.": The retainer clip, also known as the chest clip, should be positioned at armpit level to properly secure the harness straps over the baby's shoulders. Placing the clip on the baby's upper abdomen can result in improper restraint and increase the risk of injury in a crash.

A. 4+ deep-tendon reflexes B. Urine output 2.500 mL/day C. Scant lochia rubra with a few small clots D. Bilateral ankle edema

Correct Answer is A

Explanation

A. 4+ deep-tendon reflexes: Deep-tendon reflexes are typically assessed using a scale ranging from 0 to 4+, with 4+ indicating hyperactive reflexes. In a postpartum client, hyperactive deep-tendon reflexes could indicate a potential complication such as preeclampsia or eclampsia, which require immediate medical attention. Therefore, the nurse should report this finding to the provider promptly.
B. Urine output 2,500 mL/day: A urine output of 2,500 mL/day is within the expected range for a postpartum client and does not require immediate intervention. Adequate urine output is important for assessing renal function and hydration status, but this finding does not indicate an urgent concern.
C. Scant lochia rubra with a few small clots: Scant lochia rubra with small clots is a normal finding in the early postpartum period. Lochia typically progresses from rubra (red) to serosa (pink) to alba (white) over time. As long as the lochia is not excessive or accompanied by large clots, this finding is not concerning and does not require immediate reporting to the provider.
D. Bilateral ankle edema: Mild bilateral ankle edema is common in the postpartum period and is often attributed to hormonal changes and shifts in fluid balance. While the nurse should continue to monitor for signs of worsening edema or other symptoms of preeclampsia, mild edema alone is not typically considered a critical finding requiring immediate reporting to the provider.

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 on an acute care facility. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?

A nurse is teaching a class about providing care within the legal stope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?