A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?

"Complained about having incisional pain.”

"Voided adequate amounts through the shift.”

"Became short of breath when ambulating.”

"Appeared to be sleeping while in bed.”

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Complained about having incisional pain."

Choice A rationale:

Documenting a client's complaints about pain, especially incisional pain, is crucial in an electronic health record. Pain assessment and management are essential aspects of client care, and including this information helps to track the client's pain level, the effectiveness of pain interventions, and any changes in their condition over time.

Choice B rationale:

While it's important to monitor fluid intake and output, stating that the client "Voided adequate amounts through the shift" might be relevant to the client's overall condition but lacks specific information. It doesn't address the reason for the assessment, and the focus should be on the client's immediate care needs and responses.

Choice C rationale:

Noting that the client "Became short of breath when ambulating" is significant for documenting any potential signs of respiratory distress during activity. This information provides valuable insights into the client's ability to tolerate physical exertion and might indicate a need for further assessment or interventions.

Choice D rationale:

Documenting that the client "Appeared to be sleeping while in bed" might not offer significant clinical information unless there is a specific reason for noting the client's sleep patterns. Sleep is an important aspect of recovery, but this choice lacks the context needed to make it a priority entry in the documentation.

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Correct Answer is ["B","C","D"]

Explanation

The correct answer is choice b. Wash hands after removing gloves, c. Use antimicrobial hand gel after refilling a client’s water pitcher, and d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

Choice A rationale:

Placing immunocompromised clients in the same room can increase the risk of cross-infection among them. It is better to isolate them or place them in rooms with clients who have similar infection risks.

Choice B rationale:

Washing hands after removing gloves is crucial to prevent the spread of pathogens that might have contaminated the gloves during patient care.

Choice C rationale:

Using antimicrobial hand gel after refilling a client’s water pitcher helps to maintain hand hygiene and prevent the transmission of infections.

Choice D rationale:

Cleaning the stethoscope with an antimicrobial wipe after obtaining vital signs is essential to prevent the transfer of pathogens between patients.

A. Offer the client a straw to drink liquids. B. Place food toward the back of the client's mouth. C. Encourage the client to lie down and rest for 30 minutes after meals. D. Instruct the client to tilt their head forward while eating.

Correct Answer is D

Explanation

The correct answer is choice D: "Instruct the client to tilt their head forward while eating."

Choice A rationale:

Offering the client a straw to drink liquids might not be suitable for someone with dysphagia following a stroke. Straws can sometimes contribute to aspiration risk, especially if the client has difficulty controlling their swallowing reflex. Using a straw might lead to aspiration of liquids, which can be dangerous for the client's respiratory health.

Choice B rationale:

Placing food toward the back of the client's mouth could increase the risk of choking and aspiration, especially if the client has difficulty swallowing due to dysphagia. It's important to place small bites of food at the front of the mouth and encourage slow, controlled chewing and swallowing to reduce the risk of aspiration.

Choice C rationale:

Encouraging the client to lie down and rest for 30 minutes after meals is not a recommended intervention for someone with dysphagia. This position can actually increase the risk of aspiration. The client should be in an upright position while eating and for some time after eating to allow gravity to assist in preventing aspiration.

Choice D rationale:

Instructing the client to tilt their head forward while eating helps to facilitate safer swallowing by preventing food from entering the airway. This posture helps direct the food toward the esophagus and reduces the risk of aspiration. It's an essential technique for clients with dysphagia to maintain their airway safety while eating.

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A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent healthcare-associated infections for these clients? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

Correct Answer is D

Explanation

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