After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
Enter the occurrence after the 1400 notes and identify as "late entry".
Request removal initiated by the Health Information Manager.
Create an electronic correction after 1400 notes are officially unlocked.
Make an electronic addendum following the 1400 documentation.
The Correct Answer is D
A. Enter the occurrence after the 1400 notes and identify as "late entry":
While entering the occurrence after the 1400 notes is an option, labeling it as a "late entry" may not provide sufficient clarity regarding the timing of the documentation. Using a "late entry" label could potentially lead to confusion or misinterpretation.
B. Request removal initiated by the Health Information Manager:
Requesting removal of the 1400 notes by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.
C. Create an electronic correction after 1400 notes are officially unlocked:
Making an electronic correction implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.
D. Make an electronic addendum following the 1400 documentation:
An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It's important to ensure that the addendum clearly identifies the timing of the documentation to maintain accuracy and transparency in the medical record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "This unit has a policy against staff harassment."
This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.
B. "It is important to dress the right arm first."
This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.
C. "Dressing must be a frustrating experience for you."
This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.
D. "We will give you a class on dressing tomorrow."
This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.
Correct Answer is D
Explanation
A. Keeping a pair of gloves in a uniform pocket:
While it may be convenient to carry gloves, this action alone does not necessarily indicate an understanding of appropriate gloving procedures. Simply having gloves readily available does not ensure that they are used correctly or in accordance with infection control protocols.
B. Using sterile gloves when handling body fluids:
This action indicates an understanding of the need for sterile gloves when handling potentially infectious body fluids. However, it's important to note that not all situations require sterile gloves, and the use of sterile gloves should be based on the specific clinical context and infection control guidelines.
C. Donning sterile gloves when caring for clients with HIV:
While wearing gloves when caring for clients with HIV is important for infection control, not all situations require sterile gloves. The use of sterile gloves should be based on the specific clinical context and infection control guidelines.
D. Putting on new gloves when entering a client's room:
This action demonstrates an understanding of the importance of donning clean gloves when entering a client's room to prevent the spread of infection. It indicates adherence to standard precautions and proper infection control practices, making it the most appropriate choice.
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