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A nursing instructor is reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in a client record?
- A. Cover errors with correction fluid and write in correct info
- B. Put date & time on all entries
- C. Document objective data
- D. leaving out opinions
- E. Use as many abbreviations as possible
Correct Answer: B,C
Rationale: The correct answers are B and C. Putting date and time on all entries ensures accuracy and accountability. Documenting objective data maintains professionalism and avoids subjective bias. Choice A is incorrect as it can be considered tampering with records. Choice D is incorrect as opinions should be avoided for objectivity. Choice E is incorrect as excessive abbreviations can lead to misinterpretation.
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Nurse transferring client from acute-care hospital to rehab facility. Which of following info about client should nurse include in transfer report?
- A. Alert & oriented
- B. Refuses to eat spinach
- C. Has shellfish allergy
- D. Requests morphine every 4h
- E. Misses the 2 cats he has at home
- F. allergies
- G. Alertness
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A - Being alert and oriented is crucial for the client's safety and care continuity. C - Shellfish allergy is critical to prevent adverse reactions. D - Morphine request indicates pain management needs. Incorrect choices: B - Food preference is not a priority in transfer report. E - Missing pets is not pertinent medical information. F, G - General terms without specific details are not essential for transfer report.
Home health nurse is discussing dangers of food poisoning with client. What information should the nurse include? (Select all that apply)
- A. Most food poisoning is caused by viruses
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are at risk should eat/drink only pasteurized dairy products
- D. Healthy people usually recover from illness in a few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Immunocompromised individuals are at higher risk for complications from food poisoning due to weakened immune systems.
C: Clients at risk should consume only pasteurized dairy products to reduce the risk of foodborne illnesses.
E: Handling raw and fresh food separately prevents cross-contamination, a common cause of food poisoning.
Incorrect options:
A: Most food poisoning is caused by bacteria, not viruses.
D: Healthy individuals typically recover from food poisoning in a few days, not weeks.
In summary, the correct answers focus on specific preventive measures and risks for vulnerable populations, while the incorrect options provide inaccurate information regarding the causes and outcomes of food poisoning.
A nursing instructor is reviewing actions nurses can initiate without a provider's prescription. Which of the following are nurse-initiated?
- A. Give morphine 1-2 mg IV every 1h as needed
- B. Insert NG tube to relieve gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C,D,E
Rationale: The correct answers are C, D, and E. C: Nurses can educate clients on progressive muscle relaxation techniques without a prescription to promote relaxation. D: Providing daily baths is part of basic hygiene care and can be initiated by nurses without a prescription. E: Repositioning clients every 2 hours to prevent pressure ulcers is within the scope of nursing practice. A: Administering morphine requires a prescription due to the potential for adverse effects. B: Inserting an NG tube involves a medical procedure and should be prescribed by a provider.
Nurse educator is teaching module on proper body mechanics during employee orientation. Which statement by new nurse indicates need for more teaching?
- A. My line of gravity should fall outside my base of support
- B. The lower my center of gravity
- C. the more stability I have
- D. To broaden my base of support
- E. I should spread my feet apart
- F. I should hold it as close to my body as possible
Correct Answer: A
Rationale: Answer A is correct because the statement "My line of gravity should fall outside my base of support" indicates a misunderstanding of proper body mechanics. The line of gravity should fall within the base of support to maintain balance and prevent falls. Choices B, C, D, E, and F all reflect accurate understanding of body mechanics, emphasizing lowering the center of gravity, broadening the base of support, spreading feet apart for stability, and holding objects close to the body for leverage and control. Therefore, these choices do not indicate a need for more teaching.
Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.