An older adult male client, recently diagnosed with Type 2 diabetes, refuses to allow the practical nurse (PN) to stick his finger to obtain a blood glucose assessment, and states, "My fingers are sore and it's useless anyway. How should the PN document the refusal in the client's electronic medical record?

Healthcare provider notified, client refuses to have blood glucose taken.

Blood glucose not obtained because client no longer wants to have finger stick

Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified.

Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed.

Answer and Explanation

The Correct Answer is C

A. Healthcare provider notified, client refuses to have blood glucose taken: While this option indicates that the healthcare provider was informed and that the client refused, it does not fully capture the client’s expressed reason for refusal. Complete and precise documentation includes the client’s statement in their own words.
B. Blood glucose not obtained because client no longer wants to have finger stick: This phrasing is too casual and lacks the specificity needed for legal and clinical documentation. It does not reflect the client’s exact words or demonstrate that the healthcare provider was informed about the situation.
C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified: This option best meets documentation standards by including the client's direct quote, ensuring accurate and objective recording of the refusal, and noting that the healthcare provider was informed. It provides a clear, detailed account suitable for medical and legal purposes.
D. Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed: Describing the client as uncooperative and irritable is subjective and could be considered judgmental. Proper documentation should remain objective, focusing on the client’s stated concerns rather than labeling their behavior.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Provide a tepid sponge bath: Providing a tepid sponge bath is an effective non-pharmacological intervention to help lower a dangerously high fever in a child. This method promotes gentle cooling by encouraging heat loss through evaporation, helping reduce the risk of another seizure without causing abrupt temperature changes.
B. Remove blankets while shivering: Removing blankets while the child is actively shivering is not recommended because shivering can increase the body's metabolic rate and paradoxically raise the core temperature. Managing the fever should focus on gradual cooling without triggering additional metabolic heat production.
C. Apply blankets during diaphoresis: Applying blankets during diaphoresis, when the child is already sweating, can trap heat and counteract the body's natural efforts to cool down. During diaphoresis, lighter coverings or removing excess clothing is more appropriate to facilitate heat loss.
D. Turn on an oscillating fan: Although using a fan can aid in cooling by promoting air circulation, it can also cause rapid cooling, leading to shivering. Shivering increases metabolic heat production, which may worsen the child's condition during a febrile episode rather than improving it.

A. Apply lotion to sacrum. B. Use wet-to-dry dressings daily. C. Elevate head of bed 30 degrees. D. Change positions every 2 hours.

Correct Answer is D

Explanation

A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.

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Naxlex Comprehensive Predictor Exams

A pre-school age child is admitted with a febrile seizure. The practical nurse (PN) obtains an oral temperature of 104.2° F (40.1° C) during the morning assessment. Which action should the PN prepare to implement?

Correct Answer is A

Explanation

An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?

Correct Answer is D

Explanation

A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

Which disposable product should the practical nurse (PN) place in a biohazard container?

While providing oral care for a client who is unconscious, the practical nurse (PN) positions the client laterally and uses a basin to collect secretions. Which intervention is best for the PN to implement?

A client on a prescribed full liquid diet has a nursing problem of, "Risk for impaired skin integrity related to reduced oral intake." Which snack would be best to provide this client?

At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) the inability to fall asleep. Which is the priority nursing action?

The practical nurse (PN) is preparing to provide a change of shift report when an oncoming nurse arrives, appearing intoxicated, and who describes to another colleague about drinking all afternoon and almost forgetting to come to work. Which action should the PN take first?

The unlicensed assistive personnel (UAP) working in a small community hospital obtains 0800 vital sign measurements of clients on the unit. In reviewing these vital signs, which measurement warrants immediate intervention by the practical nurse?

After accepting employment in a state different from where a practical nurse (PN) is currently employed, it is most important for the PN to review which reference?