A nurse is documenting client care in the nurses' notes and notices that a space was left blank.
Which of the following actions should the nurse take?
Black out the line with a felt-tip pen.
Leave the space as it is within the entry.
Draw a horizontal line through the space and sign at the end of the line.
Place the date at the beginning of the space, followed by double lines.
The Correct Answer is C
Choice A rationale:
Blacking out the line with a felt-tip pen is not an appropriate action for correcting a blank space in the nurses' notes. It can make the entry look unprofessional and may not be accepted as a proper correction.
Choice B rationale:
Leaving the space as it is within the entry is not the correct action because it does not address the blank space or provide necessary documentation. Blank spaces in documentation should be corrected appropriately.
Choice C rationale:
Drawing a horizontal line through the space and signing at the end of the line is the correct action. This is a standard practice for correcting blank spaces in documentation. It signifies that the space was intentionally left blank and has been reviewed and approved by the nurse.
Choice D rationale:
Placing the date at the beginning of the space, followed by double lines, is not a standard or recommended method for correcting blank spaces in documentation. It can lead to confusion and may not meet documentation standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.
Choice B rationale:
Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.
Choice C rationale:
Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.
Choice D rationale:
Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.
Correct Answer is A
Explanation
The correct answer is a. Plan to remove the restraints as soon as the client is calm.
Choice A reason: The primary goal after applying restraints is to ensure the safety of the client and others. Once the client is calm, planning for the removal of restraints is essential to maintain the client’s dignity and to adhere to ethical standards of minimizing restraint use.
Choice B reason: While offering snacks is part of general care, it is not specifically related to the immediate action required following the application of restraints. Nutritional needs should be addressed, but they do not take precedence over the assessment and potential removal of restraints.
Choice C reason: Ensuring that a prescription for restraints is signed within 48 hours is a legal requirement, but it is not the immediate action to be taken following the application of restraints. The focus should be on the client’s current state and reassessing the need for continued restraint.
Choice D reason: Monitoring the client’s range of motion every 60 minutes is important to prevent complications from restraint, such as contractures or muscle atrophy. However, this is secondary to the immediate reassessment of the need for restraint and planning for its removal as soon as the client is calm.
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