A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse. Which of the following should the charge nurse include in the teaching? (select all that apply)
A medical record can be used as evidence in a court of law
A nurse should ensure the documentation is organized and completed in a timely fashion
Documentation should include the nurse's interpretation of the client situation
Data contained in a client's medical record can be shared with all employees within a health care facility
Information recorded in the client's medical record must be accurate and complete.
Correct Answer : A,B,E
A. A medical record can indeed be used as evidence in a court of law to support or refute claims related to patient care.
B. Documentation should be organized and timely to ensure accuracy and continuity of care.
C. Documentation should not include the nurse's interpretation but rather objective data and actions taken.
D. Data in a client's medical record should only be shared with those directly involved in the client's care unless otherwise authorized.
E. Information recorded in the client's medical record must be accurate and complete to support safe and effective client care and legal purposes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Atropine is not used as an antidote for warfarin overdose. It is primarily used to treat bradycardia and certain types of heart block.
B. Vitamin K is the antidote for warfarin overdose. Warfarin inhibits vitamin K-dependent clotting factors, and vitamin K helps reverse its effects by promoting clotting factor synthesis in the liver.
C. Protamine is used as an antidote for heparin, not warfarin. It binds to heparin to neutralize its anticoagulant effects.
D. Epinephrine is not used as an antidote for warfarin overdose. It is primarily used in emergencies such as severe allergic reactions (anaphylaxis) or cardiac arrest.
Correct Answer is C
Explanation
A. Lecture involves one-way communication where information is delivered by the nurse to the client without active participation. It does not confirm understanding or assess learning through client feedback.
B. Question and answer involves the nurse posing questions to assess understanding but may not actively involve the client in demonstrating knowledge or skills.
C. Teach-back is an effective teaching method where the nurse asks the client to explain the procedure back in their own words. This technique helps assess the client's understanding, clarify information, and reinforce learning, promoting patient empowerment and adherence to treatment plans.
D. Role play involves simulating scenarios to practice skills or behaviors, which may not directly assess the client's understanding of a specific procedure.
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