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. Provide a box of tissues for the client to use when coughing is a helpful action for promoting hygiene and comfort. However, this does not address the potential risk of infection transmission to staff and others in the room.

B. Obtain face masks for staff to wear upon entering the room is the most appropriate action. The client is coughing, and non-productive coughing can still release droplets that may carry infectious agents. Wearing face masks helps protect staff and other individuals from potential exposure to airborne pathogens.

C. Assist the client in changing into a fresh hospital gown is a considerate action but does not directly address the immediate concern of infection control. The priority here is preventing the spread of potential infectious particles.

D. Teach the client to cover the mouth with hands when coughing is incorrect. The client should cover their cough with their elbow or a tissue, not with their hands, to prevent spreading germs. Teaching this technique is important but does not address the immediate need for protective measures for staff.

A. Check skin for unusual bruising. B. Palpate mucus membranes for cracks. C. Monitor color of nailbeds. D. Assess skin folds of perineal area. E. Observe skin under the breasts.

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

Explanation

A. Check skin for unusual bruising is not directly related to the client's diaphoretic condition. While bruising may be relevant in some cases, it is not the priority in this scenario, where the focus is on managing moisture and skin integrity.

B. Palpate mucus membranes for cracks is not as relevant in this situation. Cracks in the mucus membranes could indicate dehydration or other issues, but the primary concern for a diaphoretic client is skin breakdown due to moisture.

C. Monitor color of nailbeds is important in general assessment, but it is not directly related to the client's diaphoretic condition. Nailbed color may indicate circulation issues, but it is not a primary concern for this scenario.

D. Assess skin folds of perineal area is important because moisture from perspiration can accumulate in skin folds, increasing the risk for skin breakdown or infection, especially in overweight clients.

E. Observe skin under the breasts is also critical. The skin under the breasts is prone to moisture buildup, which can lead to irritation, fungal infections, or skin breakdown in overweight clients. Regular assessment of this area is necessary to prevent complications.

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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

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Correct Answer is B

Explanation

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

Explanation

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