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
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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Related Questions
Correct Answer is D
Explanation
A. Gloves: Gloves are important for contact precautions but are not sufficient protection against airborne infections like tuberculosis. Tuberculosis spreads through respiratory droplets that remain suspended in the air, requiring specialized respiratory protection.
B. Gown: A gown is generally used when there is a risk of direct contact with infectious material. While gowns are important for many isolation precautions, they do not protect against airborne transmission of tuberculosis.
C. Dosimeter badge: A dosimeter badge measures exposure to radiation, not infectious agents. It is used in environments with radiologic procedures and is unrelated to protecting against infectious diseases like tuberculosis.
D. N95 respirator: An N95 respirator is specifically designed to filter airborne particles, including Mycobacterium tuberculosis. It fits tightly around the face and provides the necessary protection against inhaling infectious airborne pathogens in the client’s environment.
Correct Answer is B
Explanation
A. Request the family members leave the client's room: Family members may choose to stay if they wish, and they should be allowed to participate or be present during postmortem care if it aligns with their emotional needs or cultural practices. Forcing them to leave is not appropriate unless required for specific procedures.
B. Place dentures in the client's mouth: Placing dentures helps maintain the natural shape and appearance of the face, offering a more familiar and comforting appearance for the family during viewing. This is an important step in preparing the body respectfully.
C. Remove the client's personal hair pieces: Hairpieces should be left in place unless the family or facility policy requests otherwise. Removing them without need can alter the client’s appearance and potentially distress the family.
D. Lower the head of the client's bed: The head of the bed should be elevated slightly, not lowered, to prevent blood from pooling in the head and face, which could cause discoloration and swelling before the family views the body.
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