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 ["A","B","C","D"]

Explanation

Choice A rationale
The RN must ensure that the nurse aide has the required training to perform these tasks. This is because the RN is responsible for determining client needs and when to delegate. The RN must also ensure that the delegate is competent to perform the activity.
Choice B rationale
The RN must maintain accountability for ensuring the delegated tasks are conducted correctly and completely. This is because the RN is answerable for their own choices, decisions, and actions as measured against a standard.
Choice C rationale
The RN must ensure policies cover the delegation. This is because the RN must understand the delegation process and the state nurse practice act (NPA) to ensure that it is safely, ethically, and effectively carried out.
Choice D rationale
The RN must perform an assessment of the patient prior to delegation. This is because the RN’s decision of whether or not to delegate is based upon their judgement concerning the condition of the patient.
Choice E rationale
While observing all tasks performed by the nurse aide II is a good practice, it is not a requirement for the RN in regard to this delegated task.

A. Bradypnea. B. Hyperpnea. C. Kussmal’s Respirations. D. Cheyne-Stokes Respirations.

Correct Answer is D

Explanation

Choice D rationale
Cheyne-Stokes respirations, a pattern of breathing characterized by a gradual increase in depth and sometimes in rate to a maximum depth, followed by a decrease resulting in apnea, are commonly observed in patients nearing the end of life.

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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

Correct Answer is ["A","B","C","D"]

Explanation

The nurse is assessing a patient being cared for at the end of life. Which of the following respiratory patterns would be expected?

Correct Answer is D

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?