The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

Notify information services department of the situation.

Wait for notification that the system has been rebooted.

Identify information as late entry in the record.

Print electronic medical record (EMR) from backup server.

Answer and Explanation

The Correct Answer is A

A. Notify information services department of the situation is the correct first step. The nurse should immediately report the issue to the information services department to resolve the problem with the computer system. This ensures that the issue is addressed promptly and minimizes any delays in documentation or patient care.

B. Wait for notification that the system has been rebooted is not the best action. While waiting for the system to reboot might be necessary, the nurse should first notify the information services department to expedite the resolution of the issue.

C. Identify information as late entry in the record may be necessary once the system is restored, but the immediate priority is to report the system failure so that it can be addressed and the documentation can be completed correctly.

D. Print electronic medical record (EMR) from backup server may be an option if the system cannot be restored, but the first step should be to notify the information services department. The backup server can be used if needed after the issue is reported.

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Correct Answer is B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

A. Turgor. B. Blood pressure. C. Weight. D. Lung sounds.

Correct Answer is C

Explanation

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

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The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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