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 A
Explanation
This is because diarrhea can cause a loss of potassium along with water and other electrolytes. Potassium is an important mineral that helps regulate the heartbeat, nerve impulses and muscle contractions. Low levels of potassium can cause symptoms such as weakness, fatigue, muscle cramps, irregular heartbeat and constipation.
Choice B. Hypocalcemia is wrong because diarrhea does not usually cause a loss of
calcium. Calcium is another mineral that helps with muscle and nerve function, blood clotting and bone health. Low levels of calcium can cause symptoms such as numbness, tingling, muscle spasms, seizures and confusion.
Choice C. Hyponatremia is wrong because diarrhea can cause a loss of sodium, but not to the extent that it causes hyponatremia. Sodium is the most abundant electrolyte in the body and it helps regulate fluid balance, blood pressure and nerve and muscle function. Low levels of sodium can cause symptoms such as headache, confusion, nausea, vomiting, seizures and coma.
Choice D. Hypochloremia is wrong because diarrhea can cause a loss of chloride, but not to the extent that it causes hypochloremia. Chloride is another electrolyte that helps maintain fluid balance, blood pressure and acid-base balance. Low levels of chloride can cause symptoms such as weakness, dehydration, alkalosis (high blood pH) and muscle twitching.
The normal ranges for electrolytes in the blood are:
- Potassium: 3.5 to 5 mEq/L
- Calcium: 8.5 to 10.2 mg/dL
- Sodium: 135 to 145 mEq/L
- Chloride: 96 to 106
Correct Answer is B
Explanation
This is because the pH of gastric contents is acidic (less than 5.5) and can indicate that the tube is in the stomach. This method is predictive of the correct placement of a nasogastric tube.
Choice A is wrong because fluoroscopy is not the most reliable method to confirm the correct placement of a nasogastric tube. It is an imaging technique that uses X-rays to show the movement of the tube, but it is not always available or feasible.
Choice C is wrong because injecting air and listening for gurgling sounds is not a reliable method to confirm the correct placement of a nasogastric tube. It can cause false-positive results and does not differentiate between the stomach and the respiratory tract.
Choice D is wrong because observing for bubbles after placing the end of the tube in a cup of water is not a reliable method to confirm the correct placement of a nasogastric tube. It can also cause false-positive results and does not differentiate between the stomach and the respiratory tract.
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