A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?
"Contacted the provider to report client findings."
"Reports stomach pain as 3 on a pain scale of 0 to 10."
"Vomited 120 mL of clear, yellow emesis."
"Denies further nausea or vomiting since antiemetic administration.
The Correct Answer is D
A. "Contacted the provider to report client findings." – This is an example of collaboration or communication, not direct implementation of care.
B. "Reports stomach pain as 3 on a pain scale of 0 to 10." – This is assessment, not implementation.
C. "Vomited 120 mL of clear, yellow emesis." – This is also assessment (objective data collection).
D. "Denies further nausea or vomiting since antiemetic administration." – This is implementation, as it evaluates the effect of an intervention (antiemetic administration).
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Related Questions
Correct Answer is A
Explanation
A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.
B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.
C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.
D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.
Correct Answer is C
Explanation
A. Limit the use of hand gestures when communicating with the client. Hand gestures enhance communication for clients with hearing loss. Visual cues such as gestures, facial expressions, and lip reading can help improve understanding.
B. Speak to the client with an increased pitch. Speaking in an increased pitch is not recommended because higher frequencies are often harder for clients with hearing loss to detect. Instead, the nurse should speak clearly, slowly, and in a lower tone.
C. Use written materials to assist with communication. Written materials help clients with hearing loss understand important information, especially if they rely on lip reading or have significant hearing impairment.
D. Limit visitors to avoid communication misunderstandings. Limiting visitors is unnecessary and may lead to social isolation. Instead, the nurse should encourage communication using appropriate strategies, such as writing or sign language.
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