The client states they have an allergy to codeine. Which is the best response by the nurse?

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

Choice A rationale
A newly admitted client with a seizure disorder requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.
Choice B rationale
A post-op laparotomy client who is waiting for discharge instructions requires specific education and assessment, which is beyond the scope of practice for a nursing assistant.
Choice C rationale
A client who needs assistance with feeding is the correct answer. Assisting with feeding is within the scope of practice for a nursing assistant.
Choice D rationale
A dehydrated client with an electrolyte imbalance requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.