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Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put 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 shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.
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Nurse is preparing info for change-of-shift report. Which of the following info should nurse include in report?
- A. Client's input & output for shift
- B. Client's blood pressure from previous day
- C. Bone scan that is scheduled for today
- D. Med routine from Med Admin Record
Correct Answer: C
Rationale: The correct answer is C: Bone scan that is scheduled for today. This information is crucial to ensure continuity of care and alert the incoming nurse to any special procedures or interventions that may be required. Including the client's input & output for the shift (choice A) is important for monitoring hydration but may not be as time-sensitive as the scheduled bone scan. The client's blood pressure from the previous day (choice B) is not as relevant for immediate care unless there were notable abnormalities. The med routine from the Med Admin Record (choice D) is important but may not be as urgent as the scheduled procedure. It is essential to prioritize and communicate time-sensitive tasks to ensure the client's safety and well-being.
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. "becoming actively involved in providing guidance to next generation"
- B. adjusting to major changes in roles/relationships due to losses
- C. devoting great deal of time to establishing occupation
- D. finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because young adults typically focus on establishing their occupation during this stage of development, as per Erikson's theory of psychosocial development. This behavior reflects the stage of intimacy vs. isolation, where individuals strive to form strong relationships and establish a sense of identity through their work. Choice A is incorrect as it pertains more to the generativity vs. stagnation stage, which occurs in middle adulthood. Choice B is incorrect as it aligns with the crisis of integrity vs. despair in late adulthood. Choice D refers to the sandwich generation, which involves caring for both children and aging parents, a challenge typically faced in middle adulthood.
A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP?
- A. Feeding client who was admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching w/ client who is learning to walk using quad cane
- C. Reapplying a condom catheter for client who has urinary incontinence
- D. Applying sterile dressing to pressure ulcer
Correct Answer: C
Rationale: The correct answer is C. The nurse can assign the task of reapplying a condom catheter for a client with urinary incontinence to an unlicensed assistive personnel (AP) because it is a routine, non-invasive procedure that does not require specialized nursing skills. The AP can be trained to perform this task safely under the nurse's supervision.
A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse.
B: Teaching a client to walk using a quad cane involves assessing the client's safety and gait, which should be done by a licensed nurse.
D: Applying a sterile dressing to a pressure ulcer requires knowledge of wound care principles and infection control, which should be done by a licensed nurse.
Nurse caring for client who has new prescription. Prior to admin, nurse uses electronic database to gather info about med & effects it might have on this client. Which following component of critical thinking is nurse using when he reviews med info?
- A. knowledge
- B. experience
- C. intuition
- D. competence
Correct Answer: A
Rationale: The correct answer is A: knowledge. By reviewing medication information in an electronic database, the nurse is utilizing knowledge as a component of critical thinking. Knowledge involves the understanding of facts, evidence, and information relevant to the situation at hand, which in this case is understanding the medication and its potential effects on the client. This process allows the nurse to make informed decisions based on evidence and data.
Summary of incorrect choices:
B: Experience alone may not provide the detailed information about the medication's effects on the client.
C: Intuition is based on gut feelings rather than factual information from the database.
D: Competence is the ability to perform a task effectively, but it does not specifically address the gathering of information from a database for decision-making in this scenario.
Nurse admitting a client with acute cholecystitis to the med-surg unit. Which of the following actions are essential to the admission procedure? (Select all that apply.)
- A. Explain roles of other care delivery staff
- B. Begin discharge planning
- C. Provide info about advance directives
- D. Document the client's wishes about organ donation
- E. Introduce client to his roommate
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Explaining roles of other care delivery staff helps manage client expectations and ensures effective communication among healthcare team members.
B: Beginning discharge planning early improves continuity of care and helps prevent delays in the discharge process.
C: Providing information about advance directives ensures the client's wishes are documented and respected in case of incapacitation.
E: Introducing the client to his roommate promotes social interaction and helps create a comfortable environment for the client.
Summary:
Choice D is incorrect as documenting organ donation wishes is not directly related to the admission process for acute cholecystitis.