WEEK 3 REVIEW Q&A

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

Narrative notes (name, SN, SCC) - when documenting One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, FOCUS charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline"

recommended daily amount of urine / day

30ml (every 4 hours depending of fluid intake)

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate Client needs should be assessed before considering physical or pharmacologic restraint.

A nurse finds a client unreponsive in bed and is preparing to open the client's airway. Which of the following methods to open the airway would be most appropriate to use?

Head tilt chin life technique The method of choice for opening the airway is the head tilt-chin life method. The jaw thrust method should be used when a neck injury is possible. The chest thrust method is used to treat airway obstruction by a foreign body. What is option 4? Chin to sternum method?

A client is hospitalized for the first time. Which of the foloinw actions would the nurse take to ensure the safety of the client?

Keep unnecessary furniture out of the way. ALL side rails serve as a restraint The environment has to be clutter-free; therefore unnecessary piece of equipment or furniture have to be out of the way. Lights on are not mandatory at all times. All four side rails are considered a restraint for adult patients. It is unnecessary to keep equipment out of view.

Your patient has a history of epilepsy (seizure disorder). While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to?

Lay the pt down on their side with a pillow underneath their head. Visual spots can mean an aura (seizure notification) on side to prevent aspiration

The nurse demonstrates an important principle of postmortem care by:

Prepare the body to look as clean and natural as possible. It depends on the case of the patient if all catheters and tubes can be removed. A mortician does not declare death, that is done by a physician or two RNs. The nurse and staff should not pull the sheet over the patient's face until the family has come to say their goodbyes. The nurse and staff should prepare the body to look as clean and natural as possible.

When providing postmortem care, the nurse appropriately:

Removes all jewelry don't remove dentures - it changes shape of face/mouth you can cross arms over these, but do not tie wrists together do not put pillows under head - they could get stuck in that position

A client who is unconscious needs frequent mouth care. While performing mouth care, the nurse takes care to place the client in which of the following positions?

Side lying position In the side-lying position fluid is more likely to flow readily out of the mouth where it can be easily suctioned. Fowler's position and Tredelenburg's position are not appropriate since the unconscious patient does not have control of their airway in those positions. The supine position is unsafe as the client may aspirate the fluids.

While eating in a restaurant, a nurse notices a male patron choking on food. The indivudal is coughing loudly, his face is red, and he is unable to answer questions. Which of the following actions should the nurse take?

Stand by and further observe the individuals response when the choking individual is able to cough the nurse should do nothing to interfere with the individual's attempt to clear the obstruction. The nurse needs to intervene when air exchange is compromised.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Take the restraints off, stay with her and talk gently to her

When performing fall risk assessments, which client does the nurse determine is most at risk for falls?

a 70 year old female with postural hypotension who wears eyeglasses, but has no history of falls Risk factors for falls include age older than 65 years, documented history of falls; impaired vision or sense of balance; altered gait or posture; a medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics; postural hypotension; slowed reaction time; confusion or disorientation; impaired mobility; weakness and physical frailty; and/or an unfamiliar environment. The 70-year-old client with postural hypotension who wears eyeglasses, but has no history of falls, has three of these risk factors. The other clients listed each have only two risk factors.

A nurse organizes client data using the SOAP format. Which information would be recorded under "S" of this acronym?

client reports of pain Subjective Objective Assessment Plan

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which precautions are implemented by the nurse to prevent the spread of infection?

contact precautions

A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. What is a prudent nursing intervention for this client?

document the incident, assessment and interventions in the clients medical record ALWAYS ASSESS PT FIRST

Which part of the client's record is commonly used to document specific client variables, such as vital signs?

flow sheets Flow sheets are tables that have vertical and horizontal columns that allow nurses to document specific client variables such as vital signs, weight, intake and output, and bowel movements. Critical pathways—also known as clinical pathways, multidisciplinary pathways, collaborative paths, or care maps to name a few—utilize evidence-based practice and apply it to structured, multidisciplinary care tracts to provide guidelines for protocols and best practice. Nursing notes are notes from nurses related to the client care that are situational in nature and add a descriptive process of events or conversations. Progress notes are notes that document care from other health care professionals.

You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizure precautions:

oxygen and suction at bedside

In what type of documentation does a nurse record narrative notes in a nursing section?

source-oriented record