A nurse is preparing to report a change in a client’s condition to another health care provider.
What should the nurse include in the report?
A summary of all the interventions performed since admission.
A description of how the nurse feels about the client’s situation.
A comparison of the client’s condition with other similar cases.
A statement of facts, changes, trends, and responses to treatment.
The Correct Answer is D
A statement of facts, changes, trends, and responses to treatment. This is the best way to report a change in a client’s condition to another health care provider because it provides clear, concise, and relevant information that can help with decision making and continuity of care.
Choice A is wrong because a summary of all the interventions performed since admission is too broad and may not reflect the current situation of the client.
Choice B is wrong because a description of how the nurse feels about the client’s situation is subjective and may not be helpful for the other health care provider. Choice C is wrong because a comparison of the client’s condition with other similar cases is not specific to the individual client and may not account for differences in factors such as age, comorbidities, or preferences.
Normal ranges for vital signs, laboratory values, and other parameters may vary depending on the source and the context, but some common examples are:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: less than 120/80 mm Hg.
• Oxygen saturation: greater than 95%.
• Blood glucose: 4.0 to 7.8 mmol/L (72 to 140 mg/dL).
• Hemoglobin: 13.5 to 17.5 g/dL for males, 12.0 to 15.5 g/dL for females.
• White blood cell count: 4.0 to 11.0 x 10^9/L.
• Platelet count: 150 to 400 x 10^9/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.
• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.
• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.
• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.
• Documenting in a timely manner to minimize errors and omissions.
The other choices are wrong because:.
• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client.It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.
• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation.It can also lead to legal action if the documented events do not match the actual events.
• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.
Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.
They may vary according to different sources and standards.
Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.
Correct Answer is B
Explanation
“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.
• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.
• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.
• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.
• Documenting in a timely manner to minimize errors and omissions.
The other choices are wrong because:.
• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client.It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.
• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation.It can also lead to legal action if the documented events do not match the actual events.
• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.
Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.
They may vary according to different sources and standards.
Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.
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