Nokea
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client's comfort level is increased when the nurse breaks eye contact to type notes into the record
- B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is a legal obligation of the examining nurse
Correct Answer: C
Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.
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A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
- A. Hydrogel dressing.
- B. Exudate absorber.
- C. Wet-to-moist dressing.
- D. Transparent adhesive film.
Correct Answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.
The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?
- A. Check the client's carotid pulse.
- B. Encourage the client to get to the toilet.
- C. In a loud voice, call for help.
- D. Gently lower the client to the floor.
Correct Answer: D
Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.
A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?
- A. Jugular vein distention.
- B. Crackles in the lungs.
- C. Peripheral edema.
- D. Hepatomegaly.
Correct Answer: C
Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.
A client being discharged with a prescription for the bronchodilator theophylline is instructed to take three doses of the medication each day. Since timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
- A. 9 a.m., 1 p.m., and 5 p.m.
- B. 8 a.m., 4 p.m., and midnight.
- C. Before breakfast, before lunch, and before dinner.
- D. With breakfast, with lunch, and with dinner.
Correct Answer: B
Rationale: Theophylline should be administered on a regular around-the-clock schedule to provide the best bronchodilating effect and reduce the potential for adverse effects. The correct dosing schedule of 8 a.m., 4 p.m., and midnight ensures that the client receives consistent dosing throughout the day. Other options do not provide the necessary around-the-clock coverage. It's important to note that food may affect the absorption of the medication, which is why the dosing schedule should not be tied to meal times.
At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
- A. Leave the room and close the door to the client's room
- B. Assess the appearance of the client's surgical dressing
- C. Bring the client a prescribed PRN sedative-hypnotic
- D. Discuss symptoms of sleep deprivation with the client
Correct Answer: A
Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.