A nurse manager is reviewing documentation of nursing notes on the unit.
Which finding warrants immediate intervention.
Blank area is noted with a single straight line, followed by nurse's name, credentials, and date.
Notes are entered every fifteen minutes for a critically ill patient.
Unsigned entry is in a patient's chart.
Blue ink was used to make the note.
The Correct Answer is C
Choice A rationale
Proper documentation policy dictates that any blank or unused space within a narrative note or progress note should be secured to prevent unauthorized additions. Drawing a single straight line through the blank area and then signing with the nurse's name, credentials, and date is the correct procedure to ensure chart integrity and adherence to legal and professional standards, therefore this finding is appropriate.
Choice B rationale
For patients with high acuity or those whose condition is rapidly changing, such as critically ill patients, frequent documentation (e.g., every fifteen minutes) is required to accurately capture the dynamic nature of their physiological and psychological status. This level of detail in charting is a standard of care in critical care settings and reflects vigilant monitoring, which warrants no intervention.
Choice C rationale
An unsigned entry in a patient's chart is a significant breach of legal and professional documentation standards. All entries must be authenticated by the person making the note, including their signature and credentials, to ensure accountability and to verify the source of the information. This finding warrants immediate intervention to correct the omission and maintain the integrity of the medical record.
Choice D rationale
While black ink is often the standard for permanent records in many institutions due to its better reproduction quality in photocopies or scans, blue ink is commonly accepted in many clinical settings for handwritten entries. As long as the ink is permanent (not pencil) and legible, the use of blue ink generally does not warrant immediate intervention, though facility policy must be followed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Elderly is a demographic qualifier, not an official NANDA-I modifier, which are used to refine the meaning of the nursing diagnosis label. NANDA-I utilizes specific, scientifically derived modifiers (e.g., Deficient, Imbalanced, Ineffective) to precisely describe the state of the human response and its related factors in a standardized way.
Choice B rationale
The phrase Potential for is an older, non-NANDA-I term. Current NANDA-I uses the standardized label Risk for to denote a high vulnerability to an undesired human response. Risk for is a diagnostic concept, not a modifier itself, and indicates a diagnostic type that requires specific risk factors.
Choice C rationale
Deficient is a scientifically appropriate, officially approved NANDA-I modifier used to specify the extent or magnitude of the problem in a two-part diagnostic statement (e.g., Deficient Knowledge). It objectively describes an inadequate quantity, quality, or amount of a specific attribute, thereby standardizing the description of the patient's human response.
Choice D rationale
Room number is a logistical and administrative data point that has no scientific relevance to the patient's human response to health conditions, which is the focus of a nursing diagnosis. NANDA-I modifiers must refine the clinical meaning of the diagnostic concept, not provide a physical location.
Correct Answer is C
Explanation
Choice A rationale
While delegation requires clear communication, the statement "Do not delegate" is a procedural or ethical guideline, not an example of the specific type of communication occurring during the act of delegating an outpatient procedure, which fundamentally involves a structured exchange of information and expectations.
Choice B rationale
Non-therapeutic communication includes techniques like stereotyping, challenging, or giving false reassurance, which block or hinder the development of a trusting, constructive relationship. The structured exchange needed for safe delegation, however, must be goal-directed and professional, aiming for clarity and task completion.
Choice C rationale
Therapeutic communication is a goal-directed form of professional exchange used to build rapport, obtain information, and impart instructions. When delegating a task to UAP, the nurse employs clear, structured, and goal-oriented communication to ensure the task is understood and performed safely and correctly, fitting the definition of therapeutic communication in a professional context.
Choice D rationale
Non-verbal communication (e.g., body language, facial expressions) is always part of any interaction, but it is not the main example when delegating an outpatient procedure, which primarily relies on clear, specific verbal instructions to ensure task completion and patient safety.
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