A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

Includes quotes from the client

Remains logged in to the charting system throughout the shift

Makes reference in the nurses notes of completing an incident report

Documents that the provider wrote an inaccurate prescription

Answer and Explanation

The Correct Answer is A

A) Includes quotes from the client:

Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.

B) Remains logged in to the charting system throughout the shift:

Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.

C) Makes reference in the nurse's notes of completing an incident report:

While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.

D) Documents that the provider wrote an inaccurate prescription:

Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.

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Correct Answer is ["A","B"]

Explanation

A) Undergoing cardiac catheterization:

Cardiac catheterization is an invasive procedure that involves threading a thin tube (catheter) through blood vessels to the heart. It carries potential risks, including bleeding, infection, and damage to blood vessels or the heart. Therefore, obtaining informed consent is essential to ensure that the client understands the procedure, its risks, benefits, and alternatives before undergoing it.

B) Receiving moderate sedation:

Moderate sedation (conscious sedation) is a drug-induced state of depressed consciousness during which the client remains responsive to verbal commands. While it is less invasive than general anesthesia, it still carries risks, including respiratory depression, hypotension, and allergic reactions. Informed consent is required to ensure that the client understands the potential side effects and complications associated with sedation.

C) Suctioning a tracheostomy tube:

Suctioning a tracheostomy tube is a routine nursing intervention to remove secretions and maintain airway patency. It does not typically require informed consent unless there are specific circumstances or the client's condition warrants additional explanation or consent, such as if the client is at risk for complications or discomfort during the procedure.

D) Inserting a peripheral IV catheter:

Inserting a peripheral IV catheter is a common nursing procedure that typically does not require informed consent unless there are unusual circumstances or the client's condition warrants additional explanation or consent, such as if the client has specific concerns or medical conditions that may affect the procedure.

E) Inserting an indwelling urinary catheter:

Inserting an indwelling urinary catheter is a routine nursing procedure commonly performed to drain urine from the bladder. Informed consent may be required in certain situations, such as if the client lacks decision-making capacity or if the procedure involves specific risks or considerations that require explanation to the client or their legal representative. However, in most cases, informed consent is obtained as part of the general consent for treatment upon admission to the healthcare facility.

A. "Have you tried holding your infant skin-to-skin?" B. "is your infant able to latch on during breastfeeding?" C. "What is your infant's level of activity?" D. "Have you considered joining a parents' support group?"

Correct Answer is B

Explanation

A) "Have you tried holding your infant skin-to-skin?":

While skin-to-skin contact can be beneficial for infant bonding and comfort, the priority for a postoperative infant following a cleft palate repair is to ensure adequate feeding. While skin-to-skin contact can promote bonding and provide comfort, it does not directly address the infant's ability to latch on during breastfeeding, which is crucial for nutritional intake and healing postoperatively.

B) "Is your infant able to latch on during breastfeeding?":

This question addresses the priority concern for the nurse, which is the infant's ability to effectively latch on during breastfeeding. Adequate latch is essential for proper nutrition and hydration, especially for an infant recovering from a cleft palate repair surgery. The nurse needs to assess whether the infant can latch on properly to ensure adequate feeding and support optimal healing.

C) "What is your infant's level of activity?":

While assessing the infant's level of activity is important for overall health and well-being, it is not the priority question in this scenario. The nurse's primary focus should be on assessing the infant's feeding ability and ensuring adequate nutritional intake postoperatively.

D) "Have you considered joining a parents' support group?":

Joining a parents' support group can be valuable for emotional support and sharing experiences, but it is not the priority question in this situation. The immediate concern is ensuring the infant's nutritional needs are being met, particularly in the context of breastfeeding challenges following cleft palate repair surgery.

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A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients on a medical-surgical unit. The nurse should ensure that the client has signed an informed consent form prior to which of the following procedures? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

Correct Answer is B

Explanation

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