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

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

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

Note whether the client has a living will.

Begin charting with an evaluation of the data.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.

Choice B rationale:

Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.

Choice C rationale:

Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.

Choice D rationale:

Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.

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Correct Answer is A

Explanation

A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.

A. Place the client in the lithotomy position. B. Elicit a vagal response by performing gentle rectal stimulation. C. Administer oral bisacodyl 30 min prior to the procedure. D. Insert a lubricated gloved finger and advance along the rectal wall.

Correct Answer is D

Explanation

- A. Incorrect. The lithotomy position is not appropriate for this procedure, as it can cause discomfort and embarrassment to the client. The nurse should place the client in a left lateral Sims' position with the right knee flexed for better access to the rectum and to reduce pressure on the abdominal organs.

- B. Incorrect. The nurse should avoid eliciting a vagal response, as it can cause bradycardia, hypotension, and syncope in some clients. The nurse should monitor the client's vital signs and stop the procedure if signs of vagal stimulation occur.

- C. Incorrect. Oral bisacodyl is a stimulant laxative that can cause abdominal cramping, diarrhea, and electrolyte imbalance. It is not indicated for fecal impaction, as it can worsen the condition by increasing the bulk and hardness of the stool. The nurse should administer an enema or a stool softener before attempting digital evacuation.

- D. Correct. The nurse should insert a lubricated gloved finger and advance along the rectal wall, breaking up the stool and removing it in small pieces. The nurse should use gentle pressure and avoid injuring the rectal mucosa. The nurse should also explain the procedure to the client and obtain informed consent before performing it.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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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?