The nurse is caring for a client who trips and falls over a trash can left in the path to the bathroom. Which is part of an appropriate charting entry?

Trash can accidentally left in path to bathroom

States, "I think I only bruised my left knee."

Noncompliant with use of call bell

Seems angry and upset

Answer and Explanation

The Correct Answer is A

A. Trash can accidentally left in path to bathroom: This option accurately documents the environmental factor that contributed to the client's fall. It provides relevant information about the incident, highlighting the presence of a hazard (the trash can) in the path to the bathroom, which led to the fall. Documenting such environmental factors is essential for identifying safety issues and implementing preventive measures.

B. States, "I think I only bruised my left knee": While documenting the client's statement about the extent of their injury is important for assessing and addressing their physical condition, it does not directly address the environmental factor that contributed to the fall. This information may be included in the assessment section of the chart but may not fully capture the circumstances surrounding the fall.

C. Noncompliant with use of call bell: This statement implies a judgment about the client's behavior rather than documenting the circumstances of the fall. While noncompliance with safety measures such as using the call bell may contribute to falls, it is important to focus on objective observations and environmental factors that directly contributed to the incident.

D. Seems angry and upset: Documenting the client's emotional state is relevant for understanding their response to the fall and providing appropriate psychosocial support. However, it does not directly address the cause of the fall or provide information about the environmental factor (the trash can) that contributed to the incident.

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Correct Answer is C

Explanation

Docusate sodium is a stool softener commonly prescribed to alleviate constipation, particularly in patients taking opioid pain medications, which often cause constipation as a side effect. When educating a client about docusate sodium, it's essential to provide accurate information about its onset of action and expected effects.

A. "I can take this medication along with mineral oil."

This statement indicates a misunderstanding of the teaching. Combining docusate sodium with mineral oil is not recommended because mineral oil can interfere with the absorption of fat-soluble vitamins and may diminish the effectiveness of docusate sodium.

B. "I should drink 4 ounces of water when I take the medication."

Although it's important to stay hydrated when taking docusate sodium, there isn't typically a specific volume of water recommended for each dose. While hydration can aid in the effectiveness of the medication, this statement doesn't directly address the expected action of docusate sodium.

C. "It might take up to 3 days for the medication to work."

This statement demonstrates an understanding of the teaching. Docusate sodium may take a few days to produce a noticeable effect on bowel movements. Understanding this timeline helps manage the client's expectations and prevents premature discontinuation of the medication due to perceived lack of efficacy.

D. "I will take the medication for diarrhea."

Docusate sodium is not indicated for the treatment of diarrhea. It is specifically used as a stool softener to alleviate constipation by promoting easier passage of stool. This statement indicates a misunderstanding of the intended use of the medication.

A. ask about medications the client currently takes. B. check the client's vital signs. C. notify the healthcare provider about the bleeding. D. send the urine to the lab for culture and sensitivity.

Correct Answer is A

Explanation

A. Ask about medications the client currently takes: The first nursing action should be to gather information about potential causes of the pink coloration of the urine. Certain medications, foods, and medical conditions can cause urine discoloration. Asking about the medications the client currently takes can help identify if the pink coloration is due to a medication side effect, such as certain antibiotics, laxatives, or antipsychotics, which can cause urine to appear pink or reddish.

B. Check the client's vital signs: While assessing the client's vital signs is important for obtaining baseline data and assessing the client's overall health status, it may not provide immediate insights into the cause of the pink urine. Vital signs are unlikely to reveal the underlying cause of urine discoloration.

C. Notify the healthcare provider about the bleeding: Notifying the healthcare provider about the presence of pink urine is important, but it should not be the first action taken without gathering more information. Before contacting the healthcare provider, the nurse should assess the client's medications, recent dietary intake, and medical history to identify potential causes of the urine discoloration.

D. Send the urine to the lab for culture and sensitivity: Sending the urine to the lab for culture and sensitivity is not the first action indicated in this scenario. While urine analysis may be warranted to further evaluate the pink urine, it should be done after assessing the client's medications and obtaining additional information to determine the likely cause of the urine discoloration.

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The nurse is caring for a client who trips and falls over a trash can left in the path to the bathroom. Which is part of an appropriate charting entry?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

The nurse collects a urine sample from a newly admitted client. The color of the urine is slightly pink. The first nursing action would be to:

Correct Answer is A

Explanation

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When working with clients of any age, the nurse keeps in mind that the key to mutually-satisfying, healthy sexual relationships between partners is most often:

Which position would be appropriate for the nurse to perform an abdominal assessment?

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