The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.
The patient developed a large hematoma where the laboratory technician had drawn blood earlier in the shift.
Which statement is appropriate to enter in the patient's chart?
The patient has a painful, raised hematoma on the outer left arm after venipuncture.
The laboratory technician was unskilled and injured the patient's arm during the blood draw.
The patient likely moved during the blood draw, resulting in a bruise on the left arm.
A large bruise is present on the patient's left arm at the venipuncture site.
The Correct Answer is A
Choice A rationale
This statement provides objective and descriptive information about the patient's condition following the venipuncture. It accurately describes the physical findings (painful, raised hematoma) and the location (outer left arm) and clearly links it to the medical procedure (after venipuncture) without making assumptions or assigning blame.
Choice B rationale
This statement is inappropriate as it is judgmental and accusatory towards the laboratory technician. Medical documentation should be objective and focus on the patient's condition and care, not on personal opinions or unsubstantiated claims about the skills of healthcare professionals.
Choice C rationale
This statement is speculative and attempts to explain the cause of the hematoma without factual basis. While patient movement can contribute to bruising, stating it as a likely cause without evidence is not objective documentation and could be inaccurate.
Choice D rationale
While this statement is factual in that it describes the presence of a bruise, it lacks important details such as the size, characteristics (e.g., raised, painful), and its direct association with the venipuncture, which are relevant for a comprehensive patient record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
To convert 12: am to military time, for any time between 12: am and 12: am, the 12 is replaced with 00. Therefore, 12: am becomes 0018 in military time.
Choice B rationale
2418 is not a valid representation of time in either standard or military format. Military time ranges from 0000 to 2359.
Choice C rationale
1218 in military time represents 12: pm in standard time, not 12: am. In the afternoon and evening, 12 is added to the standard hour to convert to military time (e.g., 1 pm is 1300).
Choice D rationale
0118 in military time represents 1: am in standard time. The hour remains the same for times between 1: am and 9: am, with a leading zero added to the hour. .
Correct Answer is C
Explanation
Choice A rationale
Setting priorities involves deciding the order in which nursing interventions should be implemented based on the urgency and importance of the client's needs. While addressing pain is often a high priority, the term itself doesn't specifically describe the cognitive process of interpreting nonverbal cues as pain.
Choice B rationale
Recognizing inconsistencies involves identifying discrepancies between verbal and nonverbal cues, or between the client's stated condition and observed behaviors. While the nurse is observing nonverbal cues, the primary action here is interpreting those cues, not necessarily identifying inconsistencies.
Choice C rationale
Making inferences involves interpreting cues and drawing conclusions based on available data. The nurse observes the client's moaning, clenched hands and teeth, and diaphoresis, and infers that these signs indicate the presence of pain. This interpretation then guides the decision to administer an analgesic.
Choice D rationale
Using empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing care and may contribute to the nurse's interpretation of the client's distress, the specific cognitive process of interpreting the nonverbal cues as pain is termed making inferences.
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