A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?
Avoid quoting client comments when documenting.
Document giving a dose of pain medication just prior to administration.
Limit documentation to subjective information.
Document information telephoned in by a nurse who left the unit for the day.
The Correct Answer is A
Quoting client comments verbatim in the documentation should be avoided. Instead, the nurse should summarize or paraphrase the relevant information provided by the client. This helps to maintain confidentiality and professionalism in the documentation process.
Documenting giving a dose of pain medication just prior to administration: Documentation should accurately reflect the timing and administration of medications. It is not appropriate to document giving a dose of medication just prior to administering it, as it would not provide an accurate account of the client's care. The medication administration should be documented after it has been given.
Limiting documentation to subjective information: Documentation should include both objective and subjective information. Objective information refers to measurable and observable data, while subjective information represents the client's thoughts, feelings, and experiences.
Including both types of information provides a comprehensive view of the client's condition and the care provided.
Documenting information telephoned in by a nurse who left the unit for the day: Documentation should only include information that has been directly observed or obtained by the nurse providing care. It is not appropriate to document information telephoned in by a nurse who is not present and available to verify or provide additional details. Each nurse should be responsible for documenting their own observations and actions.
Accurate and comprehensive documentation is crucial for maintaining continuity of care, ensuring effective communication among the healthcare team, and promoting the client's safety and well-being. Nurses should adhere to institutional policies and guidelines regarding documentation practices and prioritize accuracy, confidentiality, and professionalism in their documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Fever.
Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis. The characteristic symptoms of pertussis include paroxysmal (severe and uncontrollable) coughing fits, followed by a "whooping" sound during inhalation as the child tries to catch their breath. However, specific manifestations may vary depending on the stage of the illness.
Fever is a common manifestation of pertussis. The child may have an elevated body temperature as a response to the infection. The fever is typically low-grade but can occasionally be higher.
Koplik spots in (option B) is incorrect because they are small white or bluish-grey spots with a red halo that appear on the inside of the cheeks. However, Koplik spots are characteristic of measles (rubeola) and not pertussis.
Facial erythema, or redness of the face, in (option C) is incorrect because it is not a typical manifestation of pertussis. Facial redness may be seen in other conditions such as fever, allergic reactions, or certain skin conditions.
A beefy, red tongue Is in (option D) is incorrect because it is not associated with pertussis. This description is more commonly associated with other conditions such as vitamin B12 deficiency or certain types of oral infections.
Correct Answer is B
Explanation
When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.
The other options listed are also important but should be addressed after the initial assessment and safety measures:
A. Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
C. Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
D. Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.
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