The nurse is caring for an unconscious patient.
The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.
What is the rationale for these actions?

Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel.

The nurse identifies the patient care areas in which additional assistance is required.

The nurse realizes the potential for pressure injuries and acts to prevent their development.

The nurse is following the standing orders listed in the patient's medical record.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While nursing regulations do outline standards of care, the primary rationale for frequent repositioning and padding is not solely based on delegation limitations. Preventing pressure injuries is a fundamental nursing responsibility, regardless of who performs the tasks under appropriate supervision.

Choice B rationale

Identifying patient care areas needing additional assistance is a separate aspect of nursing assessment and care planning. While repositioning and padding contribute to overall well-being, their direct rationale is the prevention of skin breakdown, not the identification of staffing needs.

Choice C rationale

Unconscious patients are at high risk for developing pressure injuries due to immobility and decreased sensation. Repositioning at least every two hours reduces prolonged pressure on bony prominences, and padding distributes pressure more evenly, both crucial interventions in preventing tissue ischemia and subsequent ulcer formation.

Choice D rationale

While standing orders may include guidelines for repositioning and skin care, the underlying rationale stems from the physiological need to prevent pressure injuries in immobile patients. The nurse's actions are based on established principles of preventing complications associated with immobility, not solely on following pre-written orders. .

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Correct Answer is C

Explanation

Choice A rationale

Subjective opinions like "pleasant to care for" lack specific, objective data about the patient's condition or care provided. Medical documentation should focus on factual observations and interventions related to the patient's health status.

Choice B rationale

"Voiding without difficulty" is a relevant observation regarding the patient's urinary function. However, it lacks specific details such as the amount, color, or clarity of the urine, which are important for a comprehensive assessment.

Choice C rationale

This statement provides specific and objective information about the patient's pain experience. It includes the patient's self-reported pain level (6/10), the location of the pain (left temporal area), and a relevant negative finding (no relief with positioning), all contributing to a clear understanding of the patient's condition.

Choice D rationale

"Onsite looks good" is vague and lacks specific details about the condition of a particular site (e.g., surgical wound, IV insertion site). Effective documentation requires descriptive terms regarding appearance, such as color, presence of drainage, swelling, or redness.

A. Data contained in a client's medical record can be shared with all employees within a health care facility. B. Documentation should include the nurse's interpretation of the client situation. C. A medical record can be used as evidence in a court of law. D. A nurse should ensure the documentation is organized and completed in a timely fashion. E. Subjective opinions should be clearly identified as such in the documentation.

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

Explanation

Choice A rationale

Data contained within a client's medical record is not for unrestricted sharing among all employees within a healthcare facility. Access to patient information is need-to-know based and role-specific, guided by HIPAA regulations and facility policies to protect patient privacy and confidentiality.

Choice B rationale

Documentation should primarily focus on objective data, nursing interventions performed, and the client's responses. The nurse's interpretation of the client's situation should be based on factual observations and assessments, clearly documented as such, rather than subjective opinions presented as facts.

Choice C rationale

A medical record serves as a legal document that can be used as evidence in a court of law. Accurate and complete documentation provides a chronological account of the patient's care, which can be crucial in legal proceedings to demonstrate the care provided and adherence to standards.

Choice D rationale

Timely, organized, and complete documentation is essential for effective communication among healthcare team members and for providing safe and quality patient care. Accurate and up-to-date records ensure continuity of care and reflect the patient's current status and interventions.

Choice E rationale

When subjective information, such as the client's feelings or statements, is documented, it should be clearly identified as such using quotes or phrases like "client states.”. This distinguishes subjective data from objective findings and ensures clarity in the medical record. .

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The nurse is caring for an unconscious patient.The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.What is the rationale for these actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Cody is going to document in Mr. Brown's medical record.Which of the following is appropriate to document? (Case #1)

Correct Answer is C

Explanation

(Select All that Apply.) Information recorded in the client's medical record must be accurate and complete.A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse.Which of the following should the charge nurse include in the teaching? (Select 3 options)

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

Explanation

Which chart entry reflects the most accurate documentation of patient data?

When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:

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A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse.Which of the following should the charge nurse include in the teaching? (Select 3 options)

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The nurse is caring for an unconscious patient.
The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.
What is the rationale for these actions?