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A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?
- A. Cooked barley
- B. Pureed broccoli
- C. Vanilla custard
- D. Lentil soup
Correct Answer: C
Rationale: The correct answer is C: Vanilla custard. A low-residue diet aims to minimize fiber intake to reduce the bulk and frequency of bowel movements. Vanilla custard is low in fiber, making it suitable for this diet. Cooked barley (A) and lentil soup (D) are high in fiber and not recommended. Pureed broccoli (B) contains fiber and should be avoided. In summary, vanilla custard is the best choice for a low-residue diet due to its low fiber content compared to the other options.
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A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all.
- A. Cover errors w/correction fluid, & write in the correct info
- B. Put the date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of the shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting the date and time on all entries is crucial for accurate documentation, ensuring a clear timeline of events for continuity of care and legal purposes.
C: Documenting objective data without opinions maintains professionalism and accuracy, preventing subjective biases from affecting the client's record.
Incorrect Choices:
A: Covering errors with correction fluid can be seen as tampering with records, potentially leading to legal issues and compromising the integrity of the documentation.
D: Using excessive abbreviations can lead to misinterpretations and errors in communication, jeopardizing patient safety and legal clarity.
E: Waiting until the end of the shift to document can result in information being missed or forgotten, impacting the quality of care and legal accountability.
A nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should the nurse document this in the client's chart?
- A. The client fell in the shower.
- B. The client states he fell in the shower & was able to get himself back into his chair.
- C. The nurse should not document this info because she did not witness the fall.
- D. The client fell in the shower & is now resting comfortably.
Correct Answer: B
Rationale: Correct Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
A nurse is caring for a client who has been sitting in a chair for 3 hours. Which of the following problems is the client at risk for developing?
- A. Stasis of secretions
- B. Muscle atrophy
- C. Pressure ulcer
- D. Fecal impaction
Correct Answer: C
Rationale: The correct answer is C: Pressure ulcer. Prolonged sitting can lead to decreased blood flow to tissues, causing pressure ulcers. Stasis of secretions (A) is more related to respiratory issues. Muscle atrophy (B) is a result of inactivity but not typically seen after only 3 hours. Fecal impaction (D) is more related to constipation, not prolonged sitting.
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
- E. Nausea
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (bradypnea), leading to shallow breathing. Orthostatic hypotension is a potential side effect due to vasodilation. Nausea is common with opioid use as they can stimulate the chemoreceptor trigger zone. Urinary incontinence (A) and diarrhea (B) are not typically associated with opioid analgesics. So, the nurse should anticipate monitoring for bradypnea, orthostatic hypotension, and nausea as potential adverse effects.
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
- A. Presence of associated symptoms
- B. Location of the pain
- C. Pain quality
- D. Aggravating & relieving factors
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. By asking about nausea and vomiting, the nurse is assessing for other symptoms that may accompany the abdominal pain, providing crucial information for a comprehensive assessment. This helps in identifying potential causes, such as gastrointestinal issues. Other choices are incorrect because B: Location of the pain, C: Pain quality, and D: Aggravating & relieving factors focus solely on the characteristics of pain itself and not on associated symptoms.