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 C

Explanation

A. frequent enuresis: Frequent enuresis refers to the involuntary loss of urine during the day or night, often associated with bedwetting. It does not specifically describe the sudden, compelling need to urinate described by the client.

B. urinary frequency: Urinary frequency is the need to urinate more often than usual, which may or may not be associated with urgency. It does not fully capture the sudden, urgent need to urinate described by the client.

C. urinary urgency: Urinary urgency is the sudden, compelling need to urinate that cannot be delayed. This aligns with the client's description of feeling like they have to go immediately and cannot wait. Therefore, this is the most appropriate choice.

D. urge incontinence: Urge incontinence involves the involuntary loss of urine associated with a sudden, strong desire to urinate. While similar to urinary urgency, it specifically refers to the leakage of urine that can occur due to the inability to reach the toilet in time after feeling the urge to urinate. However, the client's statement does not indicate actual urine leakage, making this option less appropriate than urinary urgency.

A. Daily weights, vital signs and fluid intake and output B. Monitoring temperature, fluid intake and output and administering IV fluids C. Auscultation of lung sounds. Monitoring urine color and placing an indwelling urinary catheter in the client D. Daily weights, diuretics and waist measurement

Correct Answer is A

Explanation

A. Daily weights, vital signs, and fluid intake and output: These are essential nursing assessments and interventions that can be implemented without a physician's order to monitor the client's fluid volume deficit and hypovolemia. Daily weights help assess changes in fluid status, vital signs provide information on the client's hemodynamic stability, and monitoring fluid intake and output helps track fluid balance.

B. Monitoring temperature, fluid intake and output, and administering IV fluids: While monitoring temperature and fluid intake and output are important aspects of nursing care, administering IV fluids typically requires a physician's order, especially in the context of hypovolemia. The nurse should collaborate with the healthcare team to determine the need for IV fluid therapy.

C. Auscultation of lung sounds, monitoring urine color, and placing an indwelling urinary catheter in the client: Auscultation of lung sounds and monitoring urine color are relevant assessments for fluid volume status, but placing an indwelling urinary catheter typically requires a physician's order unless there is a specific nursing protocol in place allowing nurses to insert catheters under certain circumstances.

D. Daily weights, diuretics, and waist measurement: While daily weights are appropriate for assessing fluid status, administering diuretics should be based on a physician's order and assessment findings. Waist measurement is not typically used to assess fluid volume deficit and hypovolemia.

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

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Explanation

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