The nurse is caring for a client who trips and falls over a trash can left in the path to the bathroom. Which is part of an appropriate charting entry?

Trash can accidentally left in path to bathroom

States, "I think I only bruised my left knee."

Noncompliant with use of call bell

Seems angry and upset

Answer and Explanation

The Correct Answer is A

A. Trash can accidentally left in path to bathroom: This option accurately documents the environmental factor that contributed to the client's fall. It provides relevant information about the incident, highlighting the presence of a hazard (the trash can) in the path to the bathroom, which led to the fall. Documenting such environmental factors is essential for identifying safety issues and implementing preventive measures.

B. States, "I think I only bruised my left knee": While documenting the client's statement about the extent of their injury is important for assessing and addressing their physical condition, it does not directly address the environmental factor that contributed to the fall. This information may be included in the assessment section of the chart but may not fully capture the circumstances surrounding the fall.

C. Noncompliant with use of call bell: This statement implies a judgment about the client's behavior rather than documenting the circumstances of the fall. While noncompliance with safety measures such as using the call bell may contribute to falls, it is important to focus on objective observations and environmental factors that directly contributed to the incident.

D. Seems angry and upset: Documenting the client's emotional state is relevant for understanding their response to the fall and providing appropriate psychosocial support. However, it does not directly address the cause of the fall or provide information about the environmental factor (the trash can) that contributed to the incident.

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Correct Answer is A

Explanation

A. Draw a straight line through the error with a black ink pen and initial it: This is the correct action to take when making an error while documenting in the client's chart. Drawing a single line through the error with a black ink pen ensures that the original information remains visible for auditing purposes. The nurse should then write the correct information above or adjacent to the error, initial the correction, and include the date and time. This method maintains the integrity of the documentation while clearly indicating that an error was made and corrected.

B. Use a permanent marker to draw a line through the error and write "mistaken entry": Using a permanent marker is not appropriate because it can make the chart difficult to read and may obscure the original information. Additionally, writing "mistaken entry" does not provide sufficient clarification regarding the nature of the error or the correction made.

C. Cover the mistake with correction fluid and skip a line: Using correction fluid to cover the mistake is not recommended because it can make the chart appear altered or tampered with. Skipping a line does not adequately address the error and correction, and it may lead to confusion when reviewing the documentation.

D. Erase the error and write the correct information: Erasures are not recommended in documentation as they can be perceived as altering or tampering with the chart. Additionally, erasing information may not completely remove it from the chart, and it may still be legible under certain lighting conditions or with the use of special equipment.

A. lithotomy with a drape for privacy B. Supine with arms at their sides C. left decubitus D. a position that feels most comfortable for the client

Correct Answer is B

Explanation

A. Lithotomy with a drape for privacy: The lithotomy position, where the client lies on their back with hips and knees flexed and legs supported in stirrups, is typically used for gynecological examinations or procedures. While this position provides access to the abdominal area, it is not typically used for routine abdominal assessments. Additionally, draping for privacy may not be necessary for a routine abdominal assessment.

B. Supine with arms at their sides: This is the most appropriate position for performing an abdominal assessment. In the supine position, the client lies on their back with arms at their sides, which allows for easy access to the abdomen. The supine position provides optimal relaxation of abdominal muscles and facilitates palpation and auscultation of abdominal organs.

C. Left decubitus: The left decubitus position, where the client lies on their left side with the right knee flexed, is sometimes used to facilitate gastric emptying and reduce gastroesophageal reflux. While this position may provide some access to the abdominal area, it is not typically used for routine abdominal assessments.

D. A position that feels most comfortable for the client: While it is essential to consider the client's comfort during any assessment, the position that feels most comfortable for the client may not always be the most suitable for performing an abdominal assessment. The supine position with arms at their sides is the standard position for abdominal assessments due to its ease of access and optimal relaxation of abdominal muscles.

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The nurse is caring for a client who trips and falls over a trash can left in the path to the bathroom. Which is part of an appropriate charting entry?

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