A nurse manager is teaching a newly licensed nurse about documenting information in a client's medical record. Which of the following entries by the newly licensed nurse indicates an understanding of the teaching?
"The client is uncooperative and refused to take their morning medication."
"A 2 centimeter by 2 centimeter amount of purulent drainage was noted during a dressing change."
"A medication error was made on a previous shift. The client's vital signs are stable."
"The client was administered 4 units of regular insulin."
The Correct Answer is B
Choice A reason: Documenting that a client is "uncooperative" is subjective and judgmental. Medical records should contain objective, factual information rather than personal opinions or interpretations. This entry does not meet professional standards of documentation.
Choice B reason: Documenting the exact size and description of purulent drainage is objective, measurable, and factual. This entry provides clear clinical data that can be used for ongoing assessment and treatment planning. It avoids judgmental language and adheres to proper documentation standards. This makes it the correct answer.
Choice C reason: Documenting a medication error from a previous shift is inappropriate because nurses should only document events that occurred during their own shift. Errors should be reported through incident reporting systems, not in the client’s medical record. Including this information in the chart is incorrect.
Choice D reason: While documenting medication administration is appropriate, this entry is incomplete because it lacks essential details such as the route, time, and site of administration. Proper documentation requires comprehensive information to ensure continuity of care and safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Changing clothes after working in the field is an evidence-based practice to reduce pesticide exposure. Pesticide residues can cling to clothing and cause prolonged skin contact or contaminate the home environment. This makes option A the correct answer.
Choice B reason: Applying petroleum jelly to the nostrils does not prevent pesticide inhalation. Proper protective equipment such as masks or respirators is required to reduce inhalation risk. This option is incorrect.
Choice C reason: Wiping fruits and vegetables with a dry cloth is insufficient to remove pesticide residues. Washing thoroughly with water is necessary to reduce ingestion risk. This option is incorrect.
Choice D reason: Storing protective equipment in a vehicle exposes it to heat and contamination, reducing its effectiveness. Equipment should be stored in a clean, dry, and safe environment. This option is incorrect.
Correct Answer is B
Explanation
Choice A reason: Incisional drainage positive for glucose indicates cerebrospinal fluid leakage, which is a complication, not an expected finding. This requires immediate intervention.
Choice B reason: Irritability is expected in infants postoperatively and can indicate increased intracranial pressure or discomfort. It is a common finding after shunt placement and requires monitoring.
Choice C reason: Drowsiness may occur but is concerning if excessive, as it can indicate shunt malfunction or increased intracranial pressure. It is not considered a normal expected finding.
Choice D reason: Decreased head circumference is not expected immediately after shunt placement. Head growth should stabilize over time, but a sudden decrease would be abnormal.
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