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The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Complete an adverse occurrence/incident report.

Ensure that the restraints are not too tight.

Initiate the facility’s restraint flow sheet.

Demonstrate proper securing of the restraints.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Completing an adverse occurrence/incident report is important if an incident occurs, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice B rationale

Ensuring that the restraints are not too tight is important for the client’s safety and comfort, but it does not address the improper securing of the restraints to the bedside rails. The restraints should be secured to a movable part of the bed frame, not the rails.

Choice C rationale

Initiating the facility’s restraint flow sheet is necessary for documentation, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice D rationale

Demonstrating proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.

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A. Request removal initiated by the Health Information Manager. B. Create an electronic correction after 1400 notes are officially unlocked. C. Enter the occurrence after the 1400 notes and identify as “late entry.”. D. Make an electronic addendum following the 1400 documentation.

Correct Answer is D

Explanation

Choice A rationale

Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation. This approach does not address the need to document the 0900 occurrence.

Choice B rationale

Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

Choice C rationale

Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an option, but it may not provide sufficient clarity regarding the timing of the documentation. Using a “late entry” label could potentially lead to confusion or misinterpretation.

Choice D rationale

Making an electronic addendum following the 1400 documentation is the best approach. An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It ensures accuracy and transparency in the medical record.

A. 1.015. B. 1.005. C. 1.035. D. 1.025. E. 1.025.

Correct Answer is C

Explanation

Choice A rationale

A urine specific gravity of 1.015 is within the normal range and does not indicate dehydration. Dehydration typically results in a higher urine specific gravity due to the concentration of solutes in the urine.

Choice B rationale

A urine specific gravity of 1.005 is lower than normal and indicates dilute urine, which is not consistent with dehydration. Dehydration would result in more concentrated urine with a higher specific gravity.

Choice C rationale

A urine specific gravity of 1.035 indicates highly concentrated urine, which is consistent with dehydration. When a client has a history of vomiting and diarrhea, they are likely to be dehydrated, leading to a higher urine specific gravity.

Choice D rationale

A urine specific gravity of 1.025 is slightly higher than normal but not as high as 1.035. While it may indicate some level of concentration, it is not as indicative of severe dehydration as a specific gravity of 1.035.

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The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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Take full exam for free The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

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After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Correct Answer is D

Explanation

The nurse is assessing a client who reports a 3-day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing?

Correct Answer is C

Explanation

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The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?