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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This needle size is appropriate for an intramuscular injection into the deltoid of a 175-pound adult male with a viscous fluid.
The needle length should be long enough to reach the muscle through the subcutaneous tissue, and the needle gauge should be suitable for the viscosity of the fluid. A 23-gauge needle is a common choice for intramuscular injections.
Choice A is wrong because a 1/2 inch needle is too short to reach the deltoid muscle in an adult male.
Choice C is wrong because a 1-1/2 inch needle is too long and may cause injury to the underlying nerves or blood vessels.
Choice D is wrong because a 16-gauge needle is too large and may cause excessive tissue trauma and pain.
Correct Answer is C
Explanation
Irrigating the tube with 30 mL of sterile saline as needed. This prescription should be questioned by the nurse because it may cause trauma to the kidney or dislodge the tube. The nurse should only irrigate the tube if ordered by the health care provider and with a smaller amount of fluid.
Choice A is wrong because monitoring the urine’s color and odor is an appropriate intervention for a client with a nephrostomy tube. The urine may be bloody or cloudy initially, but it should gradually clear.
Choice B is wrong because recording the intake and output every eight hours is also an appropriate intervention for a client with a nephrostomy tube. The nurse should measure and document the amount and characteristics of urine drainage and report any changes or abnormalities.
Choice D is wrong because measuring the vital signs every four hours during the day is a reasonable prescription for a client with a nephrostomy tube. The nurse should monitor the client for signs of infection, bleeding, or obstruction.
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