The new nurse works at a hospital that uses paper records. The nurse writes a narrative note about administration of a pain medication, pictured below. Based on documentation guidelines, what is one suggestion that would improve the nurse's charting?

Exhibits

Sign each entry

Leave blank spaces in charting

Identify each entry with AM/PM instead of military time (2400 hour cycle).

Use different color of ink to highlight medication administration.

Answer and Explanation

The Correct Answer is A

A. Sign each entry: Proper documentation requires each entry to be signed or initialed by the nurse to verify accountability and provide a clear record of who performed the care. This is essential for legal and professional standards.

B. Leave blank spaces in charting: Leaving blank spaces can lead to unauthorized additions or confusion and is discouraged. Documentation should be continuous and clear without gaps to maintain accuracy and integrity.

C. Identify each entry with AM/PM instead of military time (2400 hour cycle): Military time is a standard and accepted practice in healthcare settings for clarity and to avoid confusion between AM and PM. Changing to AM/PM is unnecessary and may increase error risk.

D. Use different color of ink to highlight medication administration: Using different ink colors is not a standard requirement and could complicate documentation consistency. Clear, legible, and accurate entries are more important than color coding.

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Correct Answer is B

Explanation

A. Isolating herself from the patient: Isolation of the nurse is unnecessary and not an effective way to prevent the spread of infection. Nurses are trained to provide care while using proper infection control practices, such as hand hygiene and protective equipment.

B. Washing her hands: Hand hygiene is the most effective method to prevent the spread of infections. Proper hand washing before and after patient contact reduces the risk of transmitting pathogens, including those associated with the flu and other infections.

C. Asking for a new assignment: Requesting a new assignment does not address the prevention of infection spread. Nurses are trained to follow safety protocols, including using personal protective equipment (PPE) and practicing good hygiene to protect both patients and themselves.

D. Wearing a mask: While wearing a mask can help prevent the transmission of respiratory droplets, it is not sufficient on its own. Hand hygiene remains the most important and effective strategy for preventing the spread of infections.

A. Encourage the client to share their feelings about smoking cessation B. Review the strategies for smoking cessation with the client C. Discuss the benefits of smoking cessation with the client D. Create short term goals to assist the client in smoking cessation

Correct Answer is A

Explanation

A. Encourage the client to share their feelings about smoking cessation: The affective domain of learning involves emotions, feelings, and attitudes. By encouraging the client to share their feelings, the nurse is addressing the client’s emotional response to quitting smoking.

B. Review the strategies for smoking cessation with the client: Reviewing strategies is part of the cognitive domain, which focuses on knowledge and understanding. This method addresses the intellectual aspects of learning, not the emotional or attitudinal components.

C. Discuss the benefits of smoking cessation with the client: Discussing benefits primarily involves the cognitive domain, where the client gains knowledge about the positive effects of quitting smoking. It does not directly address emotions or personal feelings.

D. Create short term goals to assist the client in smoking cessation: Creating goals relates to the psychomotor domain, which involves setting specific, measurable actions. While goal-setting is essential in behavior change, it does not directly engage the emotional or attitudinal aspects of learning.

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The new nurse works at a hospital that uses paper records. The nurse writes a narrative note about administration of a pain medication, pictured below. Based on documentation guidelines, what is one suggestion that would improve the nurse's charting? Exhibits

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The new nurse works at a hospital that uses paper records. The nurse writes a narrative note about administration of a pain medication, pictured below. Based on documentation guidelines, what is one suggestion that would improve the nurse's charting?

Exhibits