A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record.

Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

The nurse may use white out to remove the incorrect documentation and write the correct information over the white out.

The nurse should use a permanent marker to eliminate all incorrect documentation from view and initial the mistake.

The nurse should cross out the error with a double line so the original documentation may be seen and date the new entry.

The nurse should cross out the error with a single line so the original documentation can be seen and sign and date the correction.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Using white out to remove incorrect documentation and writing the correct information over the white out is not an acceptable practice according to CMS guidelines. This method does not allow for the original documentation to be seen, which is a requirement for making corrections to documentation.
Choice B rationale
Using a permanent marker to eliminate all incorrect documentation from view and initialing the mistake is also not an acceptable practice according to CMS guidelines. This method completely obscures the original documentation, which goes against the CMS requirement that all original content must be clearly identifiable.
Choice C rationale
Crossing out the error with a double line so the original documentation may be seen and dating the new entry is not specifically mentioned in the CMS guidelines. While this method does allow for the original documentation to be seen, it’s not clear whether it adheres to all CMS guidelines.
Choice D rationale
According to CMS guidelines, when making corrections to documentation, the nurse should cross out the error with a single line so the original documentation can be seen and sign and date the correction. This method ensures that all original content is clearly identifiable, which is a requirement for making corrections to documentation.

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Correct Answer is B

Explanation

Choice A rationale
While auscultating the lung fields can provide valuable information about the patient’s respiratory status, it is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.
Choice B rationale
Administering oxygen is the most appropriate action for a COPD patient with an oxygen saturation of 89%. This will help increase the patient’s oxygen saturation and alleviate their shortness of breath.
Choice C rationale
Elevating the head of the bed can help improve lung expansion and ease breathing, but it is not as immediately effective as administering oxygen.
Choice D rationale
Assisting the patient to get up to the chair is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.

A. Advocacy. B. Autonomy. C. Accountability. D. Responsibility.

Correct Answer is C

Explanation

Choice A rationale
Advocacy in nursing refers to supporting, promoting, and protecting the rights, safety, and wellbeing of patients. While it is important for nurses to be able to explain their practice, this scenario does not specifically illustrate advocacy.
Choice B rationale
Autonomy in nursing refers to the right of patients to make informed decisions about their medical care. This scenario does not specifically illustrate autonomy.
Choice C rationale
Accountability in nursing refers to being answerable for one’s actions and practice. The ability to explain one’s practice to patients and employers is a key aspect of accountability.
Choice D rationale
Responsibility in nursing refers to the obligations and duties that come with the nursing role. While being able to explain one’s practice is part of a nurse’s responsibilities, it is more directly related to accountability.

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A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air. The patient’s pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse’s priority action?

Correct Answer is B

Explanation

The nurse understands that they need to practice in a way that can be explained to the patients and employer. Which of the following terms is this an example of?

Correct Answer is C

Explanation

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A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record.

Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?