The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.
The patient developed a large hematoma where the laboratory technician had drawn blood earlier in the shift.
Which statement is appropriate to enter in the patient's chart?
The patient has a painful, raised hematoma on the outer left arm after venipuncture.
The laboratory technician was unskilled and injured the patient's arm during the blood draw.
The patient likely moved during the blood draw, resulting in a bruise on the left arm.
A large bruise is present on the patient's left arm at the venipuncture site.
The Correct Answer is A
Choice A rationale
This statement provides objective and descriptive information about the patient's condition following the venipuncture. It accurately describes the physical findings (painful, raised hematoma) and the location (outer left arm) and clearly links it to the medical procedure (after venipuncture) without making assumptions or assigning blame.
Choice B rationale
This statement is inappropriate as it is judgmental and accusatory towards the laboratory technician. Medical documentation should be objective and focus on the patient's condition and care, not on personal opinions or unsubstantiated claims about the skills of healthcare professionals.
Choice C rationale
This statement is speculative and attempts to explain the cause of the hematoma without factual basis. While patient movement can contribute to bruising, stating it as a likely cause without evidence is not objective documentation and could be inaccurate.
Choice D rationale
While this statement is factual in that it describes the presence of a bruise, it lacks important details such as the size, characteristics (e.g., raised, painful), and its direct association with the venipuncture, which are relevant for a comprehensive patient record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Using correction tape is inappropriate as it obscures the original entry, violating the principle of maintaining a clear and accurate audit trail. This makes it impossible to determine what the original error was and who made it, which is crucial for accountability and legal purposes in healthcare documentation.
Choice B rationale
Shredding the original forms and rewriting them is unacceptable because it completely eliminates the original record. This action could be interpreted as an attempt to conceal errors or misrepresent information, which carries significant legal and ethical implications in patient care documentation.
Choice C rationale
Blacking out the error with a thick marker obscures the original information, making it impossible to review the mistake and understand the context. This method does not allow for verification of the initial entry or tracking of the correction process, which is essential for maintaining accurate medical records.
Choice D rationale
Drawing a single line through the incorrect information, making the correction clearly beside it, and then initialing and dating the change maintains the integrity of the original record while indicating who made the correction and when. This method ensures transparency and accountability in documentation, adhering to legal and professional standards for error correction in medical charts.
Correct Answer is B
Explanation
Choice A rationale
Producing clinical pathways is an application of informatics, where data and technology are used to standardize care processes for specific conditions. However, this is a specific outcome of informatics rather than the overarching definition of the field itself. Informatics encompasses a broader scope than just the creation of these pathways.
Choice B rationale
Informatics in healthcare is fundamentally about managing knowledge. This involves the acquisition, storage, retrieval, analysis, and dissemination of information to improve decision-making, enhance patient care, and advance healthcare practice. Technology serves as the tool to facilitate this knowledge management.
Choice C rationale
While effective use of informatics tools might indirectly contribute to a more efficient workflow and potentially reduce some stressors, preventing burnout is not the primary definition of informatics. Burnout is a complex issue influenced by various factors beyond information and technology.
Choice D rationale
Providing a safe place to administer care is a fundamental goal of the entire healthcare system, encompassing many aspects beyond informatics. While informatics can contribute to safety through improved communication and access to information, it is not the defining purpose of the field itself.
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