When documenting, what guidelines should be followed? Select all that apply.

Documentation should express the nurse's opinion.

Documentation should include abbreviations when possible.

Documentation should be complete.

Documentation should be factual.

Documentation should be accurate.

Answer and Explanation

Correct Answer : C,D,E

A. Documentation should express the nurse's opinion: Nursing documentation must remain objective and based on observable, measurable data rather than personal opinions or interpretations. Subjective opinions can introduce bias, reduce clarity, and may have legal implications if the record is used in clinical review or litigation.

B. Documentation should include abbreviations when possible: Use of abbreviations is restricted to those approved by the facility to prevent misinterpretation and medication errors. Many abbreviations are prohibited due to safety concerns, so indiscriminate use can compromise clarity and patient safety.

C. Documentation should be complete: Comprehensive documentation ensures that all relevant aspects of patient care, including assessments, interventions, and responses, are clearly recorded. Complete records support continuity of care among healthcare providers and reduce the risk of omissions that could negatively impact patient outcomes.

D. Documentation should be factual: Documentation must be based on objective data, such as vital signs, observed behaviors, and direct patient statements. Factual recording ensures reliability, supports clinical decision-making, and provides a legally sound account of the care delivered.

E. Documentation should be accurate: Accuracy is essential to ensure that all recorded information reflects the patient’s true condition and the care provided. Errors in documentation can lead to inappropriate interventions, compromised patient safety, and legal liability for healthcare providers.

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Correct Answer is D

Explanation

A. Ensure that the device is positioned and attached appropriately: Proper positioning of a nasal cannula is important to maintain consistent oxygen delivery and prevent pressure sores, but it does not address the underlying cause of nasal dryness caused by the high flow of oxygen. This intervention alone is insufficient to relieve mucosal irritation.

B. Use a cotton tip swab to apply petroleum to the nares: Applying petroleum-based products inside the nares is contraindicated because petroleum is flammable and poses a serious fire risk when oxygen is in use. It also does not provide adequate hydration to nasal mucosa.

C. Switch the oxygen delivery device to a simple face mask: Switching to a face mask may alter oxygen delivery and does not necessarily resolve dryness. Higher flow rates through any non-humidified device can still dry the nasal passages, this may not effectively address the problem.

D. Consult with respiratory therapy about adding humidification: Adding humidification to supplemental oxygen is the most appropriate intervention for dry nares. Humidified oxygen prevents mucosal dryness, irritation, and discomfort while maintaining adequate oxygenation, particularly at flows of 4 liters per minute or higher.

A. Metabolic acidosis B. Respiratory acidosis C. Normal ABG results D. Respiratory alkalosis

Correct Answer is A

Explanation

A. Metabolic acidosis: The patient’s pH of 7.13 indicates acidemia, and the HCO3- is significantly decreased at 13.2 mEq/L, showing a primary metabolic derangement. The PaCO2 of 38.8 mmHg is within normal limits (35–45 mmHg), suggesting that respiratory compensation has not yet fully occurred. The base excess of -14.5 further supports a significant metabolic acid load. These findings are consistent with metabolic acidosis.

B. Respiratory acidosis: Respiratory acidosis is characterized by elevated PaCO2 (>45 mmHg) due to hypoventilation, which leads to a decreased pH. In this case, the patient’s PaCO2 is normal, indicating that CO2 retention is not the primary cause of acidemia. The primary disturbance is metabolic rather than respiratory.

C. Normal ABG results: Normal arterial blood gas values include pH 7.35–7.45, PaCO2 35–45 mmHg, HCO3- 22–28 mEq/L, and PaO2 80–100 mmHg. In this ABG, the pH is acidotic, HCO3- is low, and base excess is markedly negative, which clearly deviates from normal ranges, indicating a pathological process.

D. Respiratory alkalosis: Respiratory alkalosis is characterized by decreased PaCO2 (<35 mmHg) due to hyperventilation, resulting in an elevated pH. In this ABG, PaCO2 is normal and pH is low, which contradicts the pattern seen in respiratory alkalosis. The acidemia is therefore not caused by a respiratory mechanism.

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When documenting, what guidelines should be followed? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse notices the client's nares have become dry after receiving 4 liters of oxygen via nasal cannula. What is an appropriate intervention?

Correct Answer is D

Explanation

The following arterial blood gas (ABG) results indicate? pH-7.13 PaCO2-38.8 mmHg PaO2-83 mmHg HCO3-13.2 mEq/L BE-(-14.5) O2 Sat-95%

Correct Answer is A

Explanation

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