7. A 2-year-old is admitted to the Pediatric Unit with numerous bruises, fractured left humerus and several lacerations of unexplained origin. Which nursing action is a priority?a.
Report the findings to the Child Protection Agency.b.
Share this information only with other health care professionals.c.
Document this information in the chart only.d.
Share the information with the Pediatric Social Worker.
Any suspicion of child abuse should be reported to the Child Protection Agency. Options #2, #3, and #4do not provide nor plan for protection of the child.
8. Which documentation would be the most accurate when an error has been made on the flow sheet?a.
Make the record look neat by using correction fluid.b.
Draw several lines through the entry so it is not readable.c.
Write the word "error" above or beside the original words with your initials and draw a single line through theentry.d.
Cross through the error with correction fluid and write over the entry.
Out of the options, this is the best answer. Options #l and #4
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A breach in the nursing standards of careis alteration of records. The use of correction fluid cannot be used on medical records because it denotesalteration of records. Words covered by correction fluid have been deciphered with x-ray equipment.Insurance companies will not cover nurses who use correction fluid on patient records. Option #2 isincorrect. Errors should never be obliterated or covered up.
9. One hour to discharge, a postpartum client requests more peripads, diapers, tucks, and Americaine spray. Whichresponse made by the nurse would be most appropriate and demonstrate an understanding of cost effectiveness?a.
"I will be glad to get these supplies for you."b.
"It would be much better if you would just stop and pick them up on your way home."c.
"I will be happy to get them for you and pull some extras for you to take home."d.
"What items do you need until you leave to go home?"
This option is the most diplomatic response and considers cost effectiveness. Many insurance companiesview extra supplies on the day of discharge as stockpiling, and the client may be stuck with the bill. Whilesome companies may still pay the entire bill as presented, many are becoming dollar-wise and view eachbill with a critical eye. Options #1 and #3 do not consider cost effectiveness. Option #2 is an inappropriateresponse.
10. In a 7-month-oid infant, which is the best way to detect fluid retention?a.
Weigh the child daily.b.
Test the urine for hematuriac.
Measure abdominal girth weekly.d.
Count the number of wet diapers.
Fluid retention is best detected by weighing^ daily .and noting a gaining trend. Options #2 and #3 areincorrect and will not provide information regarding fluid retention. Option #4 can provide an estimationof the amount of urine output but not about fluid retention.
11. Which nursing approach would be most appropriate for obtaining a specimen from a retention catheter?a.
Disconnect the drain at the bottom of the draining bag and drain urine into a sterile container.b.
Disconnect the tubing between the catheter and the drainage bag and drain urine into a sterile container.c.
Clamp the drainage tube. When fresh urine collects, open the tubing and drain into a sterile container.d.
Use a sterile syringe and needle to obtain urine from the porthole.
This represents the appropriate process in collecting a "sterile" urine specimen. Options #1 and #2 opena closed system which allows bacteria to be introduced. Option #3 is incorrect information.
12. Which evaluation would best determine if fluid is amniotic versus urine?a.
Digital evaluationb.
pH determination of fluid.c.
Urinalysis by lab.d.
Glucose determination.
Amniotic fluid is alkaline; test with phena-phthazine (nitrazine) paper which turns blue if it is amnioticfluid. Normal vaginal and urinary secretions are acidic. Option #1 will assist in evaluating a prolapsedcord or dilation. Options #3 and #4 are incorrect.
13. The nurse would determine the client understands the collection of urine specimen for culture and sensitivity whenhe states:a.
"I will call the lab before I collect my urine."b.
"I will drink several glasses of water before the urine is collected."
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