Answer to Question 1
Correct Answer: 2
Rationale 1: The nurse does not need to document the condition of the skin and nails unless a problem is noted.
Rationale 2: Foot care is not generally recorded unless problems are noted.
Rationale 3: The nurse does not need to document the amount of time taken on foot care.
Rationale 4: The nurse does not need to document the client's comments about the foot care.
Answer to Question 2
Correct Answer: 2,3,4,5
Rationale 1: It is not necessary for the nurse to document if the client was maintaining a conversation during the bath.
Rationale 2: When evaluating the client's bath, the nurse should include the client's tolerance of the procedure.
Rationale 3: When evaluating the client's bath, the nurse should include the condition and integrity of the client's skin.
Rationale 4: When evaluating the client's bath, the nurse should include the client's strength.
Rationale 5: When evaluating the client's bath, the nurse should include the percentage of the bath done without assistance.