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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Related Questions
Correct Answer is D
Explanation
A. Aspiration is not necessary for subcutaneous insulin injections and is not recommended as it may cause unnecessary trauma.
B. Insulin injections should be administered subcutaneously, typically in the abdomen, but not specifically 2.5 cm from the navel.
C. Insulin injections are not administered into muscle but into the subcutaneous tissue.
D. NPH insulin should be gently rolled between the palms to mix evenly before administration to ensure the suspension is well-mixed.
Correct Answer is B
Explanation
A. Black, tarry stools are not an expected effect of subcutaneous heparin; this symptom should be reported to a healthcare provider.
B. Using a soft bristle toothbrush is recommended to minimize the risk of bleeding gums, which can occur due to heparin's anticoagulant effects.
C. Subcutaneous heparin should be injected into the fatty tissue of the abdomen or thigh, not deep into the muscle.
D. Easy bruising is a potential side effect of heparin but does not indicate effectiveness; it should be monitored and reported if excessive.
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