A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.
Document and describe interventions performed by the previous shift nurse.
Use standard terminology and commonly used medical abbreviations.
Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.
Do not document nursing interventions ahead of time before performing them.
Document nursing interventions performed by the nurse who is documenting.
Correct Answer : B,C,D,E
correct answers are:
B Use standard terminology and commonly used medical abbreviations.
C Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.
D o not document nursing interventions ahead of time before performing them.
E Document nursing interventions performed by the nurse who is documenting.
Nurses play a crucial role in patient care and documentation guidelines are important to ensure accuracy, completeness, and continuity of care. Using standard terminology and commonly used medical abbreviations is important to ensure that documentation is clear, concise, and easily understood by all members of the healthcare team. This practice helps avoid confusion, facilitates communication, and ensures that all healthcare professionals can accurately interpret and act upon the documented information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. By asking for a sitter to stay at the bedside to keep the client company and minimize the risk for falls, the nurse is demonstrating the ethical principle of nonmaleficence. Nonmaleficence refers to the duty to do no harm to the client, and in this case, the nurse is taking proactive steps to prevent harm to the client by ensuring their safety and well-being. Veracity (choice B) refers to the principle of truthfulness and honesty in communication, fidelity (choice C) refers to the principle of keeping promises and maintaining trust in the nurse-client relationship, and beneficence (choice D) refers to the principle of promoting good and doing what is in the best interest of the client. While all of these principles are important in nursing practice, the nurse in this scenario is primarily demonstrating nonmaleficence by taking action to prevent harm to the client.
Correct Answer is D
Explanation
The correct answer is choice D, alternating waves of air stimulate breathing. CPAP works by delivering a continuous stream of pressurized air through a mask, which is worn over the nose or nose and mouth while sleeping. This air pressure acts like a splint, holding the airway open and preventing it from collapsing during sleep. The alternating waves of air delivered by the CPAP machine help stimulate breathing, keeping the airway open and reducing the number of breathing pauses that occur during sleep. CPAP is a highly effective treatment for obstructive sleep apnea, a condition in which the airway becomes blocked during sleep, leading to breathing pauses and interrupted sleep. By keeping the airway open and stimulating breathing, CPAP helps to improve sleep quality, reduce daytime sleepiness, and improve overall health outcomes in people with sleep apnea.
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