A nurse is reviewing documentation procedures with a newly licensed nurse. Which of the following information should the nurse include?

Document care that was omitted due to a client's condition or refusal.

Collaborate with staff members to develop a list of unit-specific abbreviations.

Record subjective interpretations of the client's condition.

Document interventions based on priority instead of time.

Answer and Explanation

The Correct Answer is A

A. Document care that was omitted due to a client's condition or refusal: Accurate documentation should include any interventions that were not performed, along with the reason. This provides a complete record for legal, ethical, and continuity-of-care purposes and ensures transparency in nursing practice.

B. Collaborate with staff members to develop a list of unit-specific abbreviations: Standardized documentation requires the use of approved, universally recognized abbreviations to avoid misinterpretation. Creating unit-specific abbreviations can lead to confusion, errors, and compromised patient safety.

C. Record subjective interpretations of the client's condition: Documentation should focus on objective, factual observations and the client’s reported symptoms rather than the nurse’s personal opinions or interpretations. Subjective interpretations can introduce bias and are not considered professional documentation.

D. Document interventions based on priority instead of time: Interventions should be recorded in chronological order, noting the exact time of care. Prioritizing documentation by importance rather than time can result in incomplete or inaccurate records, compromising continuity of care and legal accuracy.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. FACES: The FACES pain scale uses facial expressions that correspond to numeric ratings, but it is designed for children who are typically 3 years of age or older and can cognitively associate faces with levels of pain. Infants cannot reliably use this tool because they lack the developmental ability to self-report.

B. FLACC: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is validated for assessing pain in infants and young children who cannot verbally communicate. It evaluates observable behaviors such as facial grimacing, limb movement, activity level, crying, and consolability, providing an objective measure of pain intensity in nonverbal populations.

C. Oucher: The Oucher scale is a self-report tool that uses photographs of children’s faces to represent pain intensity, appropriate for children around 3 to 12 years old. Infants cannot use this scale reliably because they cannot interpret or select images to indicate their pain level.

D. Visual analog: The visual analog scale requires the child or adult to mark a point along a line to represent pain intensity. It relies on abstract reasoning and self-reporting and is not suitable for infants or nonverbal children, as they cannot understand or accurately use this method.

A. Turn the newborn's head quickly to one side while they are sleeping. B. Place a finger in the newborn's palm. C. Clap hands after laying the newborn on a flat surface. D. Hold the newborn upright with one foot touching the crib surface.

Correct Answer is C

Explanation

A. Turn the newborn's head quickly to one side while they are sleeping: Turning the head quickly elicits the tonic neck reflex (also called the “fencing reflex”), not the Moro reflex. This reflex causes the newborn to extend the arm and leg on the side the head is turned while flexing the opposite limbs.

B. Place a finger in the newborn's palm: Placing a finger in the newborn’s palm elicits the palmar grasp reflex, causing the infant to curl their fingers around the object. It does not trigger the Moro reflex, which involves a startle response of the whole body.

C. Clap hands after laying the newborn on a flat surface: The Moro reflex is elicited by a sudden loss of support or a startle stimulus, such as a loud clap or gentle dropping of the infant’s head slightly backward while lying on a flat surface. The newborn responds with abduction and extension of the arms, followed by adduction and often crying.

D. Hold the newborn upright with one foot touching the crib surface: This action is used to elicit the stepping or walking reflex, in which the newborn makes stepping movements. It does not elicit the Moro reflex, which is a response to sudden displacement or loud stimuli.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reviewing documentation procedures with a newly licensed nurse. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an infant who is postoperative. Which of the following pain scales should the nurse use to evaluate the infant's pain level?

Correct Answer is B

Explanation

A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who has decreased mobility and requires repositioning every 2 hr. Which of the following outcomes should the nurse expect?

A nurse is caring for a client who has schizophrenia. The client tells the nurse, "Government agents are out to get me." Which of the following responses should the nurse make?

A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the guardian of a preschooler who has heart failure and a prescription for furosemide. Which of the following instructions should the nurse include?

A nurse is collecting data from a client who is 24 hr postoperative following a total knee arthroplasty. Which of the following findings on the operative leg should the nurse identify as a manifestation of a deep-vein thrombosis?

A nurse is reinforcing teaching with a client who was diagnosed with diabetes mellitus and requires Insulin injections. Which of the following client statements indicates an understanding of the teaching?

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

A nurse is caring for a client who has COPD. The client tells the nurse, "I get short of breath during meals. It is too much trouble to eat." Which of the following instructions should the nurse suggest?