The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care. Which actions should the nurse take to prove adherence?
1. Charting the client's response to pain medication taken
2. Describing the client as "appearing to be comfortable"
3. Leaving sufficient charting space for the previous shift to chart client teaching
4. Documenting that the client reports, "I'm so afraid of tomorrow's surgery"
5. Making a late entry regarding a client's request for pain medication
Correct Answer: 1, 4, 5
Rationale: Documentation guidelines include charting a change in a client's condition and showing that follow-up actions were taken.
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A patient admitted for depression tells a nurse that he feels so hopeless that he doesn't care if he lives or dies. The patient tells the nurse that he no longer attends church with his family. The nurse identifies that possibly the patient
1. Does not value faith the way he previously had. 2. Wishes to be left alone to reflect on his lost faith. 3. Could be experiencing spiritual distress. 4. Wants the nurse to discuss his feelings with his family.
Olfactory receptors, which are responsible for the sense of smell, are examples of:
a. baroreceptors. b. pressure receptors. c. chemoreceptors. d. air receptors.
The nurse prepares to obtain a urine sample from a client's closed drainage system. Place the procedure steps in the correct order.A) Disinfect the needle insertion site.B) Insert the needle at a 30-to 40-degree angle.C) Unclamp the catheter.D) Transfer the urine to the specimen container.E) Withdraw the required amount of urine.F) Clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes.
Fill in the blank(s) with the appropriate word(s).
The nurse is performing in assessment on a client. What should be included in this process?
A. Ability to pay for a hospital stay B. Who brought patient to the hospital C. Religious and spiritual needs D. Level of education