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.

Limit documentation to subjective information.

Document giving a dose of pain medication just prior to administration.

Document information telephoned in by a nurse who left the unit for the day.

Answer and Explanation

The Correct Answer is A

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.

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Correct Answer is B

Explanation

Applying pressure with gauze helps to control bleeding and promote clotting. The other statements are not accurate or appropriate for circumcision care: "I will apply antibiotic ointment to my baby's penis" is not recommended for Plastibell circumcision. The use of antibiotic ointment is not typically necessary or recommended unless specifically advised by the healthcare provider.

"I will wipe away yellow crusts that form around the incision" should not be done as it may disrupt the healing process. Yellow crusts are a normal part of the healing process and should be left undisturbed.

"I will make sure that my baby's diaper is applied snugly" is unrelated to circumcision care. While proper diapering is important for maintaining hygiene, it does not specifically address the care of the circumcision site.

A. Provide a stimulating environment for the client B. Use confrontation to manage the client's behavior C. Limit the number of choices for the client D. Use written signs to assist the client with locating the bathroom

Correct Answer is ["A","C","D"]

Explanation

Correct:

A. Creating a stimulating environment helps engage the client and can reduce restlessness and agitation. This can include activities, social interactions, and sensory stimulation tailored to the individual's preferences.

C. Clients with Alzheimer's disease may become overwhelmed and have difficulty making decisions when presented with too many options. By limiting choices, caregivers can help reduce confusion and frustration for the client.

D. Clients with Alzheimer's disease may experience memory impairment and difficulty with orientation. Using written signs can help them navigate their surroundings and locate essential areas, such as the bathroom. Clear and simple signs can be helpful for maintaining independence and minimizing confusion.

incorrect:

B. Confrontation, which involves challenging or arguing with the client, can escalate agitation and distress. Instead, caregivers should use techniques such as redirection, validation, and providing a calm and supportive environment to manage challenging behaviors associated with Alzheimer's disease.

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A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is ["A","C","D"]

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A nurse is reviewing the guidelines for documenting client care.

Which of the following actions should the nurse plan to take?