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

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

Leave the space as it is within the entry

Answer and Explanation

The Correct Answer is B

A. Black out the line with a felt-tip pen: Blacking out a space or entry is inappropriate because it obscures the original documentation, making the record appear altered or falsified. Medical documentation must remain clear, transparent, and legally defensible at all times.

B. Draw a horizontal line through the space and sign at the end of the line: Drawing a single horizontal line through the blank space ensures that no unauthorized additions can be made later. Signing at the end of the line maintains the integrity and completeness of the medical record, following accepted documentation standards.

C. Place the date at the beginning of the space, followed by double lines: Simply dating the space without properly securing it with a line could leave it open to later insertions. Double lines are also not a recognized standard method for handling blank spaces in documentation.

D. Leave the space as it is within the entry: Leaving a blank space unmarked can create opportunities for someone to add unauthorized information later. This poses legal and ethical risks and compromises the reliability and security of the medical record.

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Correct Answer is B

Explanation

A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.

B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.

C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.

D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.

A. Frequent swallowing B. Report of sore throat C. Dark brown blood between the teeth D. Coffee-ground appearance of emesis

Correct Answer is A

Explanation

A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.

B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.

C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.

D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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