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?- Skildor

Question 1 of 5

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.

Question 2 of 5

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.

Question 3 of 5

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition the client in the Sims' position. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct Answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

Question 4 of 5

A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?

A. Use disposable plates and utensils. B. Stay in a room with the door closed. C. Dispose of soiled dressings in plastic bags that are securely closed. D. Others who are in the same room with the client should wear a mask.

Correct Answer: C

Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.

Question 5 of 5

At a motor vehicle collision site, a nurse applies pressure to a groin wound that is bleeding profusely until emergency personnel arrive. Subsequently, the client undergoes leg amputation and sues the nurse for malpractice. What is the most likely outcome of this lawsuit?

A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is unlikely to be revoked. C. There will be no judgment against the nurse, as their actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) cannot be proved.

Correct Answer: C

Rationale: The Good Samaritan Act shields healthcare professionals who act in good faith and offer reasonable care from malpractice claims, irrespective of the client's outcome. In this scenario, the nurse stopping to render aid at the accident scene and applying pressure to the bleeding groin wound would likely be covered by the Good Samaritan Act, protecting the nurse from legal repercussions related to the subsequent leg amputation.

HESI Fundamentals

Skildor

HESI RN

HESI RN

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