Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?
“Taking fluids poorly, but more than yesterday."
"Apparently comfortable all night. Offers no complaints of pain."
"Patient says she is still slightly nauseated, would like to try some toast and tea."
"4 cm reddened area over sacrum. Skin intact, warm, and dry."
The Correct Answer is D
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.
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Correct Answer is C
Explanation
A. Scheduling admissions, discharges, and nurse staffing to keep the unit at the best occupancy and utilization. Scheduling and unit staffing are typically tasks for administrative staff rather than the direct responsibilities of an LPN.
B. Educating patients on how to use hospital computers to access information such as discharge instructions or information relative to specific medications. LPNs may be involved in patient education, including showing patients how to access relevant health information, making this a potential area of proficiency.
C. Input of data such as requests for radiographs or laboratory services. LPNs may be responsible for entering basic patient care data and service requests, making this a relevant skill in many clinical settings.
D. Programming the computer to record data from primary care providers and other healthcare workers. Programming tasks are typically not within the scope of LPN duties, as these require advanced computer skills beyond general data input.
Correct Answer is C
Explanation
A. Test the patient's reading comprehension before using visual handouts.
Testing reading comprehension can be helpful but is not sufficient on its own to assess the patient’s overall learning preferences or needs.
B. Use a hands-on approach, because it works best for most people.
While hands-on learning is effective, assuming it works best for everyone may overlook individual learning preferences.
C. Ask the patient whether he learns best visually, aurally, or kinesthetically. Asking the patient’s learning preferences enables the nurse to tailor education to the patient's strengths.
D. Use a combination of the three modes of learning to enhance learning. Combining all modes without considering the patient's preferences may not be as effective as directly addressing the patient's specific learning style.