The nurse is caring for a patient with the nursing diagnosis of ineffective airway clearance related to narrowed airways and thick sputum.
Which is an appropriate expected outcome for this patient?

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.

Choice A rationale

Informing the patient that the urinary output goal was not met, without further investigation, does not address the underlying cause of the low output and fails to implement necessary interventions. It is a superficial action that lacks a scientific basis for improving the patient's condition.

Choice B rationale

Contacting the physician for a diuretic order without first assessing the cause of the reduced urinary output could be premature and potentially harmful. Diuretics increase urine production but may not be appropriate if the low output is due to dehydration, decreased renal perfusion, or other factors. Normal urine output is typically 0.5 to 1 mL/kg/hour.

Choice C rationale

Changing the goal to match the current inadequate output is inappropriate as it lowers the standard of care and fails to address a potentially serious underlying physiological issue. The initial goal of 80 mL/hour likely reflects the patient's needs based on their condition and weight.

Choice D rationale

Reassessing the patient is the most appropriate initial action. This allows the nurse to gather crucial data such as vital signs, hydration status, medication history, and any factors that might be contributing to the decreased urinary output. Understanding the cause is essential for implementing targeted and effective interventions.