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After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
- A. Request removal initiated by the Health Information Manager.
- B. Make an electronic addendum following the 1400 documentation.
- C. Create an electronic correction after 1400 notes are officially unlocked.
- D. Enter the occurrence after the 1400 notes and identify as 'late entry.'
Correct Answer: D
Rationale: Late entries maintain accuracy.
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An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep?
- A. Ask the healthcare provider for a mild sedative for bedtime.
- B. Take an afternoon nap to make up for missed sleep.
- C. Drink a mixture of warm water, whiskey, and honey at bedtime.
- D. Establish a regular time for going to bed and getting up.
- E. Avoid drinking caffeinated beverages late in the day.
Correct Answer: D,E
Rationale: Regular schedule and avoiding caffeine improve sleep.
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?
- A. Inspects crutches to ensure rubber tips are intact.
- B. Practices bicep and triceps isometric exercises.
- C. Bears body weight on the palms of hands during the crutch gait.
- D. Progresses to foot touchdown and weight bearing of the affected leg.
Correct Answer: C
Rationale: Inspecting tips ensures safety.
The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?
- A. Send an email to facility administrators reporting the action.
- B. Dispose of the copies and continue with client care assignments.
- C. Warn the colleague that copying health information is unlawful.
- D. Communicate the colleague’s activities to the unit charge nurse.
Correct Answer: D
Rationale: Reporting ensures intervention.
A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?
- A. How many popsicles are available.
- B. The color and flavor of gelatin used.
- C. If the popsicles are completely frozen.
- D. Whether they contain pulp or fruit.
Correct Answer: C
Rationale: Pulp or fruit ensures clear liquid compliance.
Nurse’s Notes
The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intensive care unit. The client lives with his daughter and her family, who report that he is compliant with his medication regimen. The client walks every morning but has shown cognitive decline at home and has no signs of improvement. The client has been experiencing increased confusion, lethargy, and decreased appetite. He has also developed a persistent cough with greenish sputum and shortness of breath
Medical History
• Hypertension
• Heart failure
• Seasonal allergies
• Pneumonia (admitted 3 days ago)
Diagnostic Results
• White Blood Cell (WBC) count: 15,000/mm³ (4,500-11,000/mm³)
• C-reactive protein (CRP): 12 mg/L (<3 mg/L)
• Blood urea nitrogen (BUN): 25 mg/dL (7-20 mg/dL)
• Serum creatinine: 1.5 mg/dL (0.6-1.2 mg/dL)
• Chest X-ray: Bilateral infiltrates
Vital Signs
• Temperature: 38.5°C (101.3°F)
• Heart rate: 110 beats per minute
• Respiratory rate: 28 breaths per minute
• Blood pressure: 140/90 mmHg
• Oxygen saturation: 88% on room air
Provider’s Prescriptions
• Administer IV antibiotics as prescribed
• Administer oxygen therapy to maintain SpO2 > 92%
• Monitor vital signs every 4 hours
• Encourage fluid intake
• Perform chest physiotherapy
Physical Examination Results
The client appears pale and diaphoretic. He has bilateral crackles in the lower lung fields and diminished breath sounds. The client is using accessory muscles to breathe and has a productive cough with greenish sputum. His skin is warm to the touch, and he has mild peripheral edema in the lower extremities. The client is alert but disoriented to time and place.
A nurse is caring for a client in the intensive care unit. Exhibits:Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
- A. Administer diuretics as prescribed, Increase oxygen flow rate, Perform chest physiotherapy, Administer bronchodilators as prescribed, Elevate the head of the bed
- B. Acute respiratory distress syndrome (ARDS),Congestive heart failure exacerbation,Hospital-acquired pneumonia,Chronic obstructive pulmonary disease (COPD) exacerbation
- C. Oxygen saturation, Blood pressure, Respiratory rate, White blood cell count, Serum creatinine
Correct Answer:
Rationale: Hospital-acquired pneumonia fits symptoms; chest physiotherapy clears secretions; oxygen saturation and WBC monitor progress.