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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Loss of central vision: While loss of central vision can occur with various eye conditions, such as age-related macular degeneration, it is not specific to cataracts. Cataracts typically cause clouding of the lens, leading to blurred or dimmed vision rather than loss of central vision.
B. Increased intraocular pressure: Increased intraocular pressure is characteristic of conditions such as glaucoma, not cataracts. Cataracts involve clouding of the lens rather than elevated pressure within the eye.
C. Decrease in peripheral vision: Decreased peripheral vision is associated with conditions like retinitis pigmentosa or glaucoma but is not a typical finding in cataracts. Cataracts primarily affect visual acuity and clarity rather than peripheral vision.
D. A bluish-white colored pupil: A bluish-white appearance of the pupil, known as leukocoria or a white pupil reflex, can be indicative of cataracts. It occurs due to light scattering by the cloudy lens of the eye, resulting in an abnormal reflection from the pupil. This finding is characteristic of cataracts and warrants further evaluation by an ophthalmologist.
Correct Answer is C
Explanation
A. "Place the patch on your upper arm": Transdermal scopolamine patches are typically applied behind the ear, not on the upper arm. Placing the patch behind the ear allows for optimal absorption of the medication through the skin.
B. "Replace a dislodged patch onto the same location": If the patch becomes dislodged, it should not be reattached. Instead, a new patch should be applied to a different area behind the ear to prevent skin irritation and ensure continuous drug delivery.
C. "Apply the patch prior to traveling": This is the correct instruction. Transdermal scopolamine patches are applied to the skin at least 4 hours before travel to prevent motion sickness during the journey. Applying the patch in advance allows time for the medication to be absorbed into the bloodstream and provide effective symptom relief.
D. "Store unused patches in the refrigerator": Transdermal scopolamine patches do not typically require refrigeration. They should be stored at room temperature in a cool, dry place. Refrigeration may alter the integrity of the patch and affect its effectiveness.
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