While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

The client's comfort level is increased when the nurse breaks eye contact to type notes into the record.

Completing the electronic record during an interview is a legal obligation of the examining nurse.

The nurse has limited ability to observe nonverbal communication while entering the assessment electronically.

The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B reason: This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C reason: This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D reason: This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

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Correct Answer is D

Explanation

Choice A reason: Continuing the blood pressure assessment until the last Korotkoff sound is heard is not the best action to implement next. It may result in an inaccurate measurement of the diastolic pressure, as the cuff pressure may be too low to detect the sound.

Choice B reason: Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point is not a necessary action to implement next. It may not affect the accuracy of the blood pressure measurement, as the nurse already hears the Korotkoff sounds clearly.

Choice C reason: Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound is not a safe action to implement next. It may cause discomfort and injury to the client, as the cuff pressure may be too high and occlude the blood flow.

Choice D reason: Releasing the air and reinflating the cuff to 30 mm Hg above the client's previous systolic reading is the best action to implement next. It helps to avoid the auscultatory gap, which is a period of silence between the systolic and diastolic pressures. It also ensures that the cuff pressure is high enough to detect the true systolic and diastolic pressures.

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

Correct Answer is A

Explanation

Choice A reason: This is the correct action because the nurse should obtain the specimen as soon as possible to avoid delays in diagnosis and treatment. The color and consistency of the stool do not affect the test for occult blood.

Choice B reason: This is not necessary because the nurse does not need to obtain a prescription or approval from the healthcare provider to collect a stool specimen for occult blood. The nurse should follow the standard protocol for specimen collection and labeling.

Choice C reason: This is incorrect because withholding specimen collection until tarry black stool is observed would delay the detection of occult blood. Tarry black stool indicates a bleeding source in the upper gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

Choice D reason: This is also incorrect because waiting to obtain the specimen until observable blood is present would also delay the detection of occult blood. Observable blood indicates a bleeding source in the lower gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

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While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

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Naxlex Comprehensive Predictor Exams

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

Correct Answer is D

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

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