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 ["A","E"]
Explanation
Correct answers are:
A. Documenting an assessment that was not performed
E. The nurse documents blood labs were sent before the blood draw was performed
Falsification of health records refers to deliberately misrepresenting, fabricating, or altering documentation, which could lead to severe consequences for patients and healthcare providers. In option A, documenting an assessment that was not performed is falsification of health records because it misrepresents the care provided to the patient. Similarly, in option E, documenting that blood labs were sent before the blood draw was performed is a falsification of health records because it is not an accurate representation of the actual order of events.
Options B, C, and D do not involve falsification of health records, but they may be considered documentation errors or violations of organizational policies.
Correct Answer is ["725"]
Explanation
Intake = IV fluid + antibiotic
From 0700-0900 (2 hours), the patient received 100 mL/hr of IV fluid: 100 mL/hr x 2 hours = 200 mL
From 1000-1030 (0.5 hours), the patient received Kefzol 1 g in 25 mL of D5W over 30 minutes:
25 mL
From 1030-1530 (5 hours), the patient received 100 mL/hr of IV fluid: 100 mL/hr x 5 hours = 500 mL
Total intake from 0700-1530 = 200 mL + 25 mL + 500 mL = 725 mL. Therefore, the patient's intake from 0700 to 1530 was 725 mL.
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