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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Initiate oxygen therapy via nasal cannula for a client who has COPD:
Clients with chronic obstructive pulmonary disease (COPD) often have impaired gas exchange and may experience acute exacerbations requiring oxygen therapy to improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical intervention to address hypoxemia and prevent complications such as respiratory failure. Therefore, initiating oxygen therapy for a client with COPD is the highest priority among the options provided.
B) Initiate a 24-hr urine collection for a client who has end-stage kidney disease:
Initiating a 24-hour urine collection is an important nursing task for clients with end-stage kidney disease to monitor renal function and assess urine output. However, compared to the immediate need for oxygen therapy in a client with COPD, starting a urine collection is a lower priority and can be scheduled once the client's respiratory needs are addressed.
C) Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:
Administering antibiotics for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection is important to control the spread of infection and prevent complications. However, unless the client's condition is critically unstable or the antibiotic administration is time-sensitive, addressing oxygenation needs for a client with COPD takes precedence due to the potential for respiratory compromise and hypoxemia.
D) Change the dressing for a client who has a decubitus ulcer:
Changing dressings for clients with decubitus ulcers is essential for wound care management and prevention of infection. While maintaining skin integrity is important, addressing respiratory distress in a client with COPD is a higher priority to ensure adequate oxygenation and prevent respiratory compromise.
Correct Answer is B
Explanation
A) Notify the nurse manager:
While it's essential to involve the nurse manager in situations involving unexpected events or emergencies, the immediate priority is to assess the well-being of the fainting family member. Notifying the nurse manager can be done after ensuring the family member's immediate needs are addressed.
B) Check the family member's vital signs:
The first action the nurse should take is to assess the fainting family member's vital signs to determine their current physiological status. Checking vital signs can provide crucial information about the person's condition and guide further actions. This assessment helps ensure the family member's safety and well-being.
C) Obtain the family member's health history:
Obtaining the family member's health history is important for understanding any underlying medical conditions that may have contributed to the fainting episode. However, assessing vital signs takes precedence to address any immediate medical concerns related to the fainting episode.
D) Complete an incident report:
Completing an incident report is necessary to document the fainting episode for organizational records and quality improvement purposes. However, this task can be completed after addressing the immediate needs of the fainting family member and ensuring their safety.
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