A charge nurse is teaching a newly hired nurse about the facility's computerized documentation system. Which of the following actions should the nurse
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a. direct the newly hired nurse to wait until the end of the shift to document client care
b. instruct the newly hired nurse to use direct quotes when recording client statements
c. perform documentation for the newly hired nurse until the orientation period is complete
d. Print records from previously discharged clients as examples for the newly hired nurse to review
ANSWER: b. instruct the newly hired nurse to use direct quotes when recording client statements
rationale:
a. The charge nurse should instruct the newly hired nurse to document client care throughout the shift. Documenting care as it is performed helps to reduce the risk of errors or omissions.
b. The newly hired nurse should include both subjective data, what the client says, and objective data, what the nurse observes, when entering computer documentation. It is important to directly quote what the client says rather than summarizing to provide factual information.
c. The charge nurse should not perform documentation for another staff member. The exception is when a staff member has left the facility and forgot to record pertinent information.
d. The charge nurse should only show the newly hired nurse records of clients that they are caring for to protect the confidentiality of other clients.
A nurse is completing an informed consent document for a 16-year-old adolescent who is married and is scheduled for an emergency appendectomy. Which of the following actions should the nurse take?
a. locate the adolescent's partner to sign the form prior to the appendectomy
b. document consent is implied due to the urgency of the procedure
c. tell the client that a general consent to treatment covers the surgical procedure
d. ask the client if they understand the provider's plan for the appendectomy
ANSWER: d. ask the client if they understand the provider's plan for the appendectomy
rationale:
a. The nurse should identify that the client's partner can sign a consent form only if the client is unable or incompetent to do so.
b. The nurse should identify that implied consent is used for noninvasive procedures, such as obtaining vital signs, in which the client implies consent by allowing the action to take place.
c. The nurse should recognize that a general consent to treatment does not address invasive and high-risk procedures.
d. To ensure informed consent, the nurse should ask the client if they understand the planned procedure. In most states, a married adolescent is considered emancipated, and has the legal authority to provide their own consent.
A nurse is admitting a client to an acute care facility. Which of the following actions by the nurse promotes client self-determination?
a. reviewing the policy on safeguarding personal valuables with the client
b. informing the client's family about the regulations for visitation hours
c. providing the client with information about end-of-life decision-making
d. comparing the client's home medications to the admission prescriptions
ANSWER: c. providing the client with information about end-of-life decision-making
rationale:
a. The nurse should assist the client to protect their valuables to prevent theft.
b. The nurse should inform the client's family about visitation regulations to promote rest for the client.
c. By promoting the client's autonomy, the nurse ensures the client's ability to self-determine care. Under the Patient Self-Determination Act, facilities must ensure a client is aware of their rights to make choices about their care, including completing advance directives to predetermine end-of-life treatment options.
d. The nurse should compare the client's home medications to the admission prescription to promote client safety.
A nurse is delegating tasks for four clients. Which of the following tasks should the nurse delegate to the assistive personnel (AP)?
a. prepare the room for a client who requires seizure precautions
b. check a client's deep tendon reflexes (DTR)
c. develop a plan of care for a client who is at risk for falling
d. obtain a wound culture on a client who has a small pressure injury
ANSWER: a. prepare the room for a client who requires seizure precautions
rationale:
a. An AP can set up a room with the equipment a client requires for seizure precautions because the necessary equipment is the same for each client.
b. A nurse cannot delegate checking a client's deep tendon reflexes to an AP because this task requires the assessment skills of a nurse.
c. A nurse cannot delegate developing a plan of care to an AP because this task requires use of the nursing process.
d. A nurse cannot delegate obtaining a wound culture to an AP because this task requires nursing knowledge and judgment.
A nurse is caring for a client who is recovering from a stroke and tells the nurse he is concerned about paying his medical bills. The nurse should refer the client to which of the following members of the interprofessional health care team?
a. physical therapist
b. occupational therapist
c. social worker
d. speech pathologist
ANSWER: c. social worker
rationale:
a. A physical therapist can assist the client with musculoskeletal problems.
b. An occupational therapist can assist the client with skills to perform activities of daily living.
c. The nurse should refer the client to a social worker to assist the client with finding available financial resources.
d. A speech pathologist can assist the client who is experiencing dysphagia.
A nurse is planning care for four clients. Which of the following clients should the nurse see first?
a. a client who has diabetes mellitus and a fasting blood glucose of 68 mg/dL
b. a client who has moderate serosanguineous drainage on a surgical dressing
c. a client who has pneumonia and expiratory wheezing
d. a client who has a PCA pump and reports pain as a 7 on a scale of 0-10
ANSWER: c.
rationale:
a. The nurse should assess a client who has a blood glucose level of 68 mg/dL and provide them with a snack; however, the nurse should assess another client first.
b. The nurse should assess this client to monitor the drainage on the surgical dressing; however, the nurse should assess another client first.
c. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to assess the client's airway and breathing, which could be impaired as a as a result of the pneumonia. When using the airway, breathing, circulation approach to client care, the nurse should plan to see the client who has pneumonia and expiratory wheezing first. The nurse should auscultate the client's lungs and measure their oxygen saturation.
d. The nurse should assess a client who reports pain as a 7 on a scale of 0 to 10 to determine if the client can receive additional pain medication; however, the nurse should assess another client first.
A nurse is reviewing the medical record for a client who is receiving continuous enteral feedings. Which of the following findings should the nurse report to the provider?
a. gastric residual of 50 mL
b. weight gain of 0.23 kg (0.5 lb) in 24 hr
c. blood glucose of 105 mg/dL
d. gastric aspirate pH of 7
ANSWER: d. gastric aspirate pH of 7
rationale:
a. The nurse should report a gastric residual of greater than 100 mL for a client who is receiving continuous enteral feedings. A high gastric residual can indicate delayed gastric emptying and increases the client's risk for aspiration.
b. The nurse should identify that a weight gain of more than 0.91 kg (2 lb) in 24 hr is a manifestation of fluid volume excess and places the client at risk for heart failure.
c. The nurse should identify that a blood glucose of 105 mg/dL is within the expected reference range of 74 to 106 mg/dL.
d. The nurse should identify that a gastric pH of 7 is an indication the nasogastric tube is not in the stomach. Gastric pH is usually between 1 and 4 but can be up to 6, if the client receives a medication that alters gastric pH. The client is at risk for aspiration and the nurse should report this finding to the provider. [Show Less]