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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ask the client which language they would like the written materials.While providing written materials in the client’s preferred language is important for communication, this does not directly address the client's vision loss. It may help with understanding but does not enhance their ability to see the materials.
B. Ensure the client has access to all corrective eyewear.This is the most appropriate intervention. Ensuring that the client has access to corrective eyewear, such as glasses or contact lenses, will help maximize their remaining vision. This is a practical and supportive action for someone with moderate vision loss.
C. Speak in a loud voice directly at the patient.Vision loss does not imply hearing impairment, so speaking in a loud voice is unnecessary and could be confusing or frustrating for the client. Communication should be clear and normal in volume, not assuming a hearing deficit.
D. Place the client close to the nurse's station.Placing the client close to the nurse’s station may enhance safety and allow for quicker assistance. However, it is not specifically related to addressing the client's vision loss and may not be necessary depending on their overall condition.
Correct Answer is A
Explanation
The correct answer is choice A, low-calorie dense foods. Low-calorie dense foods are those that have fewer calories per unit of volume, such as fruits, vegetables, and lean protein sources. These foods can help the client feel full and satisfied while still consuming fewer calories, which is important for weight loss. High trans fat foods (choice B) and high-glycemic index foods (choice C) should be avoided or limited as they can contribute to weight gain and other health problems. Highcalorie dense foods (choice D) should also be avoided or limited as they can provide too many calories without providing enough nutrients.
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