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 C

Explanation

A. Increased balance: Aging typically results in decreased balance due to changes in the musculoskeletal and nervous systems. Older adults often experience a decline in coordination and proprioception, which can increase the risk of falls.

B. Increased muscle mass: Muscle mass generally decreases with age, a condition known as sarcopenia. This loss contributes to reduced strength and endurance, making physical activity and mobility more difficult for older adults.

C. Increased joint stiffness: Joint stiffness is a common age-related change caused by decreased synovial fluid, cartilage wear, and reduced flexibility. This can limit mobility and make daily activities more challenging for elderly clients.

D. Increased calcification of bones: With aging, bones tend to lose density and become more porous, leading to conditions like osteoporosis. Calcification may occur in soft tissues, but bone itself typically becomes weaker, not more calcified.

A. Pedal Pulses B. Skin Integrity C. Intake and Output D. Temperature

Correct Answer is C

Explanation

A. Pedal Pulses: While assessing pedal pulses can provide information about circulation, they are not a direct indicator of hydration status. Pulse quality may be affected by other factors such as vascular disease or cardiac output, making this a less reliable measure.

B. Skin Integrity: Skin integrity assesses for potential breakdown or wounds. Although dehydration can affect skin turgor, this alone is insufficient to evaluate fluid balance comprehensively, especially in older adults where elasticity changes naturally with age.

C. Intake and Output: Monitoring fluid intake and urine output provides the most accurate and immediate data on fluid balance. It helps determine if the patient is retaining, losing, or maintaining fluids, making it a primary tool for assessing hydration.

D. Temperature: Elevated temperature may indicate infection or inflammation, which can contribute to fluid loss, but temperature changes alone are not a reliable measure of overall fluid status. It is an indirect and nonspecific indicator.

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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

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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