A nurse is documenting an incident report for a medication error that occurred on her unit.

Which of the following actions should the nurse take?

(Select all that apply.).

Include factual information about what happened.

State opinions about who was responsible for the error.

File the report in the client’s medical record.

Notify the risk management department.

Discuss possible solutions to prevent future errors.

Answer and Explanation

Correct Answer : A,D

The nurse should include factual information about what happened and notify the risk management department. These actions are part of the steps of reporting medication errors and the good practice guide on recording, coding, reporting and assessment of medication errors.

Choice B is wrong because the nurse should not state opinions about who was responsible for the error.

This could be seen as biased, unprofessional or accusatory.

The nurse should focus on the facts and the causes of the error, not on blaming individuals.

Choice C is wrong because the nurse should not file the report in the client’s medical record.

This could violate the client’s privacy and confidentiality.

The report should be filed in a separate system that is accessible only to authorized personnel.

Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.

This could be premature, unrealistic or inappropriate.

The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.

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Correct Answer is ["A","B","C"]

Explanation

Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care.Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs.Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.

Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate.Documentation should be factual, accurate, and objective.

Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement.Documentation should also reflect the patient’s perspective, preferences, and goals.Documentation should be patient-centered, holistic, and individualized.

Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.

However, some general ranges are:.

• Temperature: 36.5°C to 37.5°C.

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg or lower.

• Oxygen saturation: 95% or higher.

Sources:.

A. Data. B. Problem. C. Focus. D. Assessment.

Correct Answer is C

Explanation

Focus.

Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.

The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.

Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.

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A nurse is documenting an incident report for a medication error that occurred on her unit. Which of the following actions should the nurse take? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these statements about documentation are true? (Select all that apply.).

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is C

Explanation

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A nurse is documenting an incident report for a medication error that occurred on her unit.

Which of the following actions should the nurse take?

(Select all that apply.).