NCLEX study guide
Which statement reflects appropriate documentation in the medical record of a hospitalized client? "Small pressure injury noted on left leg." "Client seems to be mad at the provider." "Client had a good day." "Client's skin is moist and cool."
"Client's skin is moist and cool." Documentation should include data that the nurse obtains only by hearing, seeing, smelling, or feeling. The nurse should record findings or observations precisely and accurately. Documentation of a leg injury should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day does not provide precise enough information to be useful.
A client with benign prostatic hypertrophy is being transferred from the emergency department to a surgery unit. Which information should be included in the report from the nurse in the emergency department to the nurse responsible for admitting the client? "A urine specimen was obtained from the client and sent to the laboratory for analysis." "The client was catheterized, and 1100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory." "The client is very cooperative. The client is comfortable now that their bladder has been emptied. They have no ill effects from catheterization." "The client was in the emergency department for 3 hours because of bladder distention. The client is fine now but is being admitted as a possible candidate for surgery."
"The client was catheterized, and 1100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory." A report about the client's condition should be as clear, pertinent, and concise as possible. It should be free of subjective information that could be interpreted differently by different caregivers. The report mentioning that a specimen was sent to the laboratory does not indicate how much urine had been drained from the client's bladder and how the urine appeared. The report describing the client as cooperative is subjective and provides only limited client data. The report that mentions that the client was in the emergency department for 3 hours does not mention the treatment provided.
Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? Bring a small glass of juice, and locate the client. Call the client's health care provider (HCP). Check the computerized care plan to determine what test was scheduled. Send the nurse's assistant to the x-ray department to bring the client back to the room.
Check the computerized care plan to determine what test was scheduled. Glulisine is a rapid-acting insulin with an action onset of 15 minutes. The client could experience hypoglycemia with the insulin in the bloodstream and no breakfast. It is not necessary to call the client's HCP; the nurse should determine what test was scheduled and then locate the client and provide either breakfast or 4 oz (120 mL) of fruit juice. To bring the client back to the room would be wasting valuable time needed to prevent or correct hypoglycemia.
A teenage client is to be admitted for a fractured shoulder after being impaled on a fence running away from local police. The nurse learns that the teen lives on the street with surrogate parents. Once the client is assessed and treated, which would be the most appropriate action? Notify the police that the client is being released. Have security escort the client out of the hospital. Contact social services to advocate for the teen. Arrange visiting nurse services for follow-up care.
Contact social services to advocate for the teen. As this client is a minor, is living on the streets with a "found family," and was running from the police, social services is the appropriate first point of contact to advocate on the teen's behalf and coordinate with necessary resources. Based on the information presented, it is inappropriate to notify the police. There is no information suggesting that hospital security should be involved or that the teen must be escorted from the facility. Arranging visiting nurse services is unhelpful as the child has no fixed abode; it might be helpful to refer the client to a community clinic or mobile clinic.
Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? Evaluate the client for voluntary admission to a mental health facility. Discuss what the family can do to chemically restrain the client at home. Tell the parents that the client's behavior releases them from the duty of care. Arrange for respite care; family members could be aggravating the client's condition.
Evaluate the client for voluntary admission to a mental health facility. A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical restraints would violate the client's rights to freedom from the use of restraints and seclusion. The duty of care is a legal concept that applies only to the nurse-client relationship, not to family relationships. Respite care isn't an appropriate recommendation at this time. The nurse must address the safety issue and institute effective treatment and care. At a later time, it would be prudent for the nurse to talk with the client's family about caregiver burden and the option of using respite care.
A 15-year-old client who is 26 weeks pregnant has been admitted to the labor and delivery unit with reports of abdominal pain. Her parents want to speak with a nurse about her condition. How should the nurse respond? "I'll need a signed consent from your daughter to give you medical information." "The health care provider can give you more information without consent." "She will be OK. It's just a stomachache." "She is experiencing Braxton Hicks contractions and is too young to understand the difference between these contractions and labor pains."
I'll need a signed consent from your daughter to give you medical information A pregnant minor is emancipated from her parents so she can make decisions for herself and her baby. Therefore, the client's right to confidentiality means that neither the nurse nor the health care provider may divulge medical information without a signed consent.
A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. What should the nurse do? Reinforce the UAP's use of this intervention over the bony prominence. Explain to the UAP that massage is effective because it improves blood flow to the area. Inform the UAP that massage is even more effective when combined with the use of lotion. Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.
Instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure injury formation.
A nurse is working on a busy medical-surgical unit. What nursing actions can be viewed as a felony related to documentation? Select all that apply. The nurse documents an application of a barrier cream to a client's excoriated skin 2 hours late. The nurse documents the client's medication was given after the client refused the medication. The nurse accepts a telephone order for a laxative and administers the medication 3 hours later. The nurse documents vital signs every 5 minutes after a client experiences chest pain. The nurse documents random hourly urine outputs to the flow sheet at the end of the shift.
The nurse documents the client's medication was given after the client refused the medication. The nurse documents random hourly urine outputs to the flow sheet at the end of the shift. Falsification of documentation is a felony. The nurse's documentation of the client's medication being given after the client refused the medication and the nurse's addition of urine outputs to the flowsheet at the end of the shift are examples of falsification. The nurse's applying barrier cream and administrating a laxative later than prescribed are not falsifications. The nurse's documentation of vital signs every 5 minutes is standard practice for a client with chest pain.
A nurse takes informed consent from a client scheduled for abdominal surgery. Which is the most appropriate principle behind informed consent? protects the client's right to self-determination in health care decision making helps the client refuse treatment that he or she does not wish to undergo helps the client to make a living will regarding future health care required provides the client with in-depth knowledge about the treatment options available
protects the client's right to self-determination in health care decision making Informed consent protects the client's right to self-determination in healthcare decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.
