The nurse knows that documentation should record the interventions and the care given to the client.
What is the rationale?

It is a legal record of accountability for protection of the client and the nurse.

It supports confidentiality and privacy and should never.

It provides continuous reference for all care providers to refer to.

it provides a framework for clients rights and records if they are violated.

Answer and Explanation

The Correct Answer is A

It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.

Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.

Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.

Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.

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Correct Answer is A

Explanation

Do not eat or drink for 12 hours prior to the test. This is because fasting is required for a total serum cholesterol test to get accurate results. Fasting means not eating or drinking anything except water for 9 to 12 hours before the test.

Choice B is wrong because eliminating all dietary cholesterol for one week before the test is not necessary and will not affect the test results. Dietary cholesterol only accounts for a small portion of the total cholesterol in the blood.

Choice C is wrong because avoiding caffeinated beverages for several days prior to the test is not required and will not influence the test results. Caffeine does not affect cholesterol levels.

Choice D is wrong because stopping eating eggs and drinking milk for two days before the test is not needed and will not change the test results. Eggs and milk contain cholesterol, but they also have other nutrients that may lower the risk of heart disease.

Normal ranges for total serum cholesterol are less than 200 mg/dL (5.18 mmol/L) for adults. Higher levels may indicate an increased risk of heart disease and stroke.

A. Select an insulin syringe, 31 gauge 6 mm needle and inject insulin at a 45-degree angle. B. Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. C. Select a 0.5 mL syringe, 29 gauge 8 mm needle, pinch the skin, and inject at 45 degrees. D. Select a 1.0 mL syringe, 28 gauge 12.7 mm needle, and inject at 90 degrees.

Correct Answer is B

Explanation

Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. This is because Humulin R is a clear and colorless solution that can be given by subcutaneous injection.

A 0.5 mL syringe can hold up to 50 units of insulin, which is enough for the prescribed dose of 7 units. A 30 gauge, 8 mm needle is suitable for thin patients with poor skin turgor. Injecting at a 90-degree angle ensures that the insulin reaches the subcutaneous tissue and not the muscle.

Choice A is wrong because a 31 gauge, 6 mm needle is too short and may not deliver the insulin into the subcutaneous tissue.

Choice C is wrong because pinching the skin is not necessary for thin patients with poor skin turgor.

Choice D is wrong because a 1.0 mL syringe is too large for the prescribed dose of 7 units and may cause dosing errors. A 28 gauge, 12.7 mm needle is too long and may inject the insulin into the muscle, which can affect its absorption and action.

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The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?

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Naxlex Comprehensive Predictor Exams

A client is scheduled for a “total serum cholesterol” lab test. Which instruction to the client should be discussed to ensure adequate preparation for the test?

Correct Answer is A

Explanation

The client has diabetes Type I, a body mass index (BMI) of 17 and poor skin turgor. How should the nurse plan to administer the prescribed. Humulin R 7 units subcutaneously?

Correct Answer is B

Explanation

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The nurse knows that documentation should record the interventions and the care given to the client.
What is the rationale?