Nokea
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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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 manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.
Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: The correct answers are C and D.
C: The client scheduled for a TURP (transurethral resection of the prostate) can be safely discharged as this surgery is elective and not urgent.
D: The client who is 24 hours post-op after a mastectomy can also be discharged as they are stable and beyond the immediate post-operative phase.
A: Client receiving IV fluids for dehydration should not be discharged as they require ongoing treatment and monitoring.
B: Client with an NG tube for a small bowel obstruction should not be discharged as they require close observation and treatment.
E: Client scheduled for an appendectomy should not be discharged as this procedure is likely urgent and may require immediate attention.
Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers for fussiness and loose stools.
C: Asking about a specific food can pinpoint the culprit causing the symptoms.
D: Vomiting could indicate a more serious issue, so this question helps assess the severity of the symptoms.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding more foods could worsen the issue.
E: Making a generalization about how babies react to new foods is not helpful in this specific case.
Nurse educator conducting parenting class for new parents. Which statement made by participant indicates need for further teaching?
- A. I will begin swimming lessons as soon as my baby can close her mouth under water
- B. Once my baby can sit up, he should be safe in the bathtub
- C. I will test the temperature of water before placing baby in bath
- D. Once my infant starts to push up, I will remove mobile from over the bed
Correct Answer: B
Rationale: The correct answer is B. It indicates a need for further teaching because simply being able to sit up does not ensure safety in the bathtub. Babies can easily slip or slide, leading to potential accidents. Testing water temperature (Choice C) and removing hazards (Choice D) show proper safety awareness. Beginning swimming lessons (Choice A) is not recommended for infants. Other choices are not provided, but they would likely focus on safety measures and parenting practices.