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 B
Explanation
: Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction. This is the appropriate technique to assess pupillary reaction. The nurse should stand to the side of the patient and use a penlight or other focused light source to illuminate one pupil at a time. The light should be directed from the side of the eye, not directly in front of it, to avoid stimulating the accommodation reflex. The nurse should observe for constriction of the pupil, which should occur in response to the light. This assessment is important because changes in pupil size and reactivity can indicate neurological dysfunction or other medical conditions.
Correct Answer is A
Explanation
The correct answer is choice A: "The JP drain uses negative suction to drain fluid from the wound." The purpose of the Jackson-Pratt drain is to remove excess fluid or blood from the surgical site. This drain uses a bulb-like container that creates negative pressure or suction, which allows the fluid to be removed from the wound into the container. It is important to maintain negative pressure to ensure that the drain is functioning properly. The nurse should also instruct the client on how to monitor the drainage and how often to empty the container, and to report any changes in the amount, color, or odor of the fluid to the healthcare provider.
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