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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
When analyzing cues, the nurse should identify HCTZ, QD, QOD .1 mg, and >180mg systolic as error-prone abbreviations. Medications names, such as hydrochlorothiazide, should be spelled out. QD should be written as daily and QOD should be written as every other day. Decimal points should be written using a leading zero and greater than and less than should be written out rather than using symbols.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}
Explanation
The nurse is planning care for the client. The nurse should place the client in a High Fowler's or Semi Fowler's position.
- High Fowler's Position: Elevating the head of the bed to a high Fowler's position (60-90 degrees) can help improve breathing and oxygenation by allowing the lungs to expand more easily.
- Semi Fowler's Position: A semi Fowler's position (30-45 degrees) is also beneficial for respiratory distress, providing some elevation to aid in breathing while being more comfortable than lying flat.
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