The nurse makes an error while documenting in the client's chart. The nurse should:

draw a straight line through the error with a black ink pen and initial it.

use a permanent marker to draw a line through the error and write "mistaken entry".

cover the mistake with correction fluid and skip a line.

erase the error and write the correct information.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is D

Explanation

A. Responsibility: Responsibility refers to the duty or obligation to fulfill one's role or tasks appropriately. While advocating for the client may be considered a responsibility of the nurse, the specific action described in the scenario—calling the insurance company to strongly explain the client's need for rehabilitation—is more accurately categorized as advocacy.

B. Confidentiality: Confidentiality pertains to protecting the privacy and confidentiality of patient information. The scenario does not involve the disclosure of confidential information but rather advocating for the client's needs regarding their rehabilitation placement.

C. Social justice: Social justice involves promoting fairness, equality, and equitable access to resources and opportunities for all members of society. While advocating for the client may align with principles of social justice, the specific action described in the scenario—calling the insurance company to argue for the client's rehabilitation placement—is more directly related to individual advocacy rather than addressing broader societal inequalities.

D. Advocacy: Advocacy refers to actively supporting and speaking up for the rights, needs, and interests of others. In this scenario, the nurse advocates for the elderly client by calling the insurance company to strongly explain why the client needs to go to a rehabilitation facility despite the facility's refusal. This action demonstrates the nurse's commitment to ensuring the client receives appropriate care and support.

A. Use open-ended questions to find out about the sensation. B. Offer the client a pain scale to quantify the current level of pain C. Question the client about the location of the pain. D. Ask about what precipitates the pain.

Correct Answer is B

Explanation

A. Use open-ended questions to find out about the sensation: While open-ended questions can help the nurse gather information about the nature and quality of the pain, they may not provide a precise measure of pain intensity. Open-ended questions are valuable for understanding the client's subjective experience of pain, but they may not be as effective as using a pain scale for quantifying pain intensity.

B. Offer the client a pain scale to quantify the current level of pain: This is the most appropriate action for assessing pain intensity. Pain scales, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), allow clients to indicate their pain intensity on a scale from 0 to 10 or by marking a point along a continuum. Pain scales provide a standardized method for quantifying pain intensity, which helps healthcare providers monitor changes in pain over time and assess the effectiveness of pain management interventions.

C. Question the client about the location of the pain: While identifying the location of pain is important for understanding its source and potential underlying causes, it does not directly assess pain intensity. Location is one aspect of pain assessment but does not provide a complete picture of pain intensity on its own.

D. Ask about what precipitates the pain: Understanding what precipitates or exacerbates pain is important for comprehensive pain assessment, but it focuses more on pain triggers rather than pain intensity. While this information can be valuable for developing a holistic pain management plan, it does not directly assess the current level of pain intensity.

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The nurse makes an error while documenting in the client's chart. The nurse should:

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Correct Answer is D

Explanation

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Correct Answer is B

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