The nurse made an error in a narrative documentation of an assessment finding on a client.
The nurse should take which action to correct the error?
Documenting a late entry into the client's record.
Trying to erase the error for space to write in the correct data.
Marking the entry "mistaken entry" and adding the correct information.
Using whiteout to delete the error to write in the correct data.
The Correct Answer is C
Choice A rationale
Documentation errors must be corrected immediately within the entry rather than creating a separate late entry. Late entries are reserved for adding omitted information that was forgotten at the time of the original charting. Relying on late entries to fix simple clerical or assessment errors can create confusion in the chronological legal record. Standard nursing practice requires the correction to be integrated into the original note to maintain a clear and accurate timeline of care.
Choice B rationale
Erasing an entry is strictly prohibited in medical legal documentation because it suggests an attempt to hide or alter the patient record. Every entry must remain legible to ensure transparency and accountability. If a nurse erases data, the integrity of the entire chart is compromised, making it indefensible in a court of law. Proper technique involves maintaining the visibility of the original text while clearly indicating that an error was made by the documenting professional.
Choice C rationale
The standard procedure for correcting a narrative documentation error involves drawing a single line through the incorrect information, labeling it as a mistaken entry, and then recording the accurate data. This method ensures the original text remains readable while clearly identifying the correction. It preserves the legal integrity of the medical record by demonstrating transparency. Most facilities require the nurse to initial and date the correction to provide a clear audit trail of the change.
Choice D rationale
Using correction fluid or whiteout is never acceptable in clinical documentation because it permanently obscures the underlying information. Like erasing, this practice raises suspicions of tampering or falsifying records during legal reviews. Professional standards require that all parts of a medical record remain visible even if they are incorrect. Modern electronic and paper systems are designed to track changes without deleting the original input, ensuring that the history of the patient's care remains completely intact.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse correctly identifies that 50 bowel sounds per minute exceed the normal range of 5 to 30 sounds per minute, warranting the classification of hyperactive. This increased frequency of peristaltic waves is a classic sign of hypermotility in the gastrointestinal tract. When the intestines move this rapidly, there is insufficient time for the colon to reabsorb water from the fecal matter, which typically results in the client experiencing frequent, loose, or watery stools known as diarrhea.
Choice B rationale
Hypoactive bowel sounds represent a decrease in the frequency of intestinal contractions, usually defined as fewer than 5 sounds per minute. This slow motility allows for excessive water reabsorption, leading to hard stools and constipation. Because the client has 50 sounds per minute, this choice is scientifically inaccurate. The findings do not support a diagnosis of constipation, which is physiologically characterized by a lethargic or slowed gastrointestinal transit time and reduced frequency of bowel sounds.
Choice C rationale
Borborygmi are loud, rumbling sounds caused by the movement of gas through the intestines, and while they can be associated with hyperactive states, they are specifically the sound rather than the rate. While high-pitched, tinkling sounds can occur proximal to an intestinal obstruction, the most common clinical association for a general rate of 50 sounds per minute is diarrhea. Obstruction eventually leads to silent or absent sounds distal to the blockage, making diarrhea the more immediate anticipation.
Choice D rationale
Documenting 50 sounds per minute as normal is a clinical error because the standard physiological range for bowel sounds is 5 to 30 per minute. Expecting regular movements based on this data ignores the evidence of gastrointestinal distress. Normal bowel sounds suggest a balanced rate of peristalsis and fluid absorption. The presence of 50 sounds per minute is a clear deviation from homeostasis, indicating that the client's digestive process is currently accelerated and likely to be problematic.
Correct Answer is A
Explanation
Choice A rationale
Sodium is the primary cation found in the extracellular fluid and plays a critical role in maintaining osmotic pressure and fluid volume. The normal serum sodium range is 135 to 145 mEq/L. Because water follows sodium, it is the most significant factor in determining the distribution of water between the intracellular and extracellular compartments. It is essential for nerve impulse transmission and muscle contraction, and its concentration is tightly regulated by the kidneys and hormones like aldosterone.
Choice B rationale
Potassium is the most abundant cation in the intracellular fluid, not the extracellular fluid. The normal serum range for potassium is 3.5 to 5.0 mEq/L, which is much lower than the sodium concentration in the blood. While its extracellular concentration is small, it is vital for maintaining the resting membrane potential of cells, particularly in cardiac and skeletal muscle. Small shifts in extracellular potassium can have profound effects on heart rhythm, but it remains predominantly an intracellular electrolyte.
Choice C rationale
Calcium is a vital electrolyte for bone health, blood coagulation, and neuromuscular signaling, but it is not the most abundant in the extracellular fluid. The normal total serum calcium range is approximately 8.5 to 10.5 mg/dL. Most of the body's calcium is stored in the skeletal system rather than circulating in the plasma or interstitial fluid. While its presence in the extracellular fluid is crucial for physiological functions, its molar concentration is significantly lower than that of sodium.
Choice D rationale
Magnesium is the second most abundant intracellular cation after potassium and is involved in hundreds of enzymatic reactions, including protein synthesis and DNA repair. The normal serum magnesium range is 1.3 to 2.1 mEq/L. Although it is present in the extracellular fluid and is necessary for cardiovascular and neuromuscular health, its concentration is relatively low compared to sodium. It does not exert the same level of osmotic pull or represent the majority of the extracellular solute load.
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