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 C

Explanation

A. Check for neck vein distention is important for assessing cardiovascular status, but it is not the first priority when accessory muscle use indicates potential respiratory distress.

B. Auscultate heart sounds is a useful assessment for cardiac issues but does not directly address the immediate concern of respiratory effort and oxygenation.

C. Measure oxygen saturation is the first priority because accessory muscle use suggests increased respiratory effort, which may indicate hypoxemia. Measuring oxygen saturation provides immediate information about the client’s oxygenation status and guides further interventions.

D. Determine pulse pressure is not directly relevant to the observation of accessory muscle use and would not address the immediate respiratory concern.

A. Obtain the specimen from the client's current bowel movement. B. Withhold specimen collection until tarry black stool is observed. C. Contact the healthcare provider before obtaining the specimen. D. Wait to obtain the specimen until observable blood is present.

Correct Answer is A

Explanation

A. Obtain the specimen from the client's current bowel movement is the correct action. Occult blood can be present even in normal-appearing stool. The nurse should obtain the specimen from the current bowel movement, as it is part of the protocol for testing for hidden blood in the stool. The stool does not need to be tarry or black to test for occult blood.

B. Withhold specimen collection until tarry black stool is observed is incorrect. Tarry black stools often indicate the presence of digested blood, but occult blood testing is designed to detect blood that may not be visible to the naked eye, even in normal-colored stool.

C. Contact the healthcare provider before obtaining the specimen is unnecessary. The nurse can proceed with the collection as per the standard procedure without needing to contact the healthcare provider, unless there is a specific reason to do so.

D. Wait to obtain the specimen until observable blood is present is incorrect. The purpose of an occult blood test is to detect hidden (occult) blood, which may not be visible to the eye. The nurse should not wait for visible blood to appear before collecting the specimen.

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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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Correct Answer is A

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