What actions taken by a newly licensed nurse are appropriate when documenting on paper? Select all that apply.

The newly licensed nurse corrects an erroneous written entry using correction fluid.

The newly licensed nurse documents when there is a change in the patient's status.

The newly licensed nurse leaves a line blank so the charge nurse can add additional documentation between the newly licensed nurse's entries.

The newly licensed nurse plans to finish charting the procedure when they return from break.

The newly licensed nurse charts using military (24-hour) time.

Answer and Explanation

Correct Answer : B,E

Choice A rationale:

Using correction fluid to correct an erroneous written entry is not appropriate as it can obscure the information and raise questions about the accuracy of the documentation. It is better to strike through the error with a single line, write the correct information, and sign and date the correction.

Choice B rationale:

Documenting changes in the patient's status is crucial for ensuring continuity of care and keeping all healthcare providers informed about the patient's condition.

Choice C rationale:

Leaving a blank line for the charge nurse to add additional documentation is not recommended. Each entry should be complete and include all relevant information at the time of documentation.

Choice D rationale:

Planning to finish charting the procedure after returning from a break is not appropriate. Charting should be done in real-time to ensure accuracy and timeliness of the information.

Choice E rationale:

Charting using military (24-hour) time is appropriate as it reduces confusion and ensures a standardized way of documenting time across different healthcare settings.

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Correct Answer is A

Explanation

Choice A rationale:

"I'm sorry, I didn't hear what you said about your job. Please tell me again.”. This response demonstrates active listening and empathy. It acknowledges the patient's feelings and encourages them to share their concerns, promoting therapeutic communication. By asking the patient to repeat what they said, the nurse shows genuine interest in understanding the patient's emotions and concerns, fostering trust and rapport.

Choice B rationale:

"Why are you crying so hard about your job? What happened to your job?" This response, while well-intentioned, may come across as intrusive and judgmental. It does not encourage open communication and may make the patient feel defensive, hindering the nurse-patient relationship.

Choice C rationale:

"It's natural to be worried about your job. We all worry about our jobs sometimes.”. While this response acknowledges the patient's feelings, it does not address the specific concern the patient mentioned. It generalizes the situation and does not invite the patient to share more about their feelings, missing an opportunity for deeper communication and understanding.

Choice D rationale:

"Your job must be important to you since you are talking about it.”. This response makes an assumption about the importance of the patient's job without allowing the patient to express their feelings. It does not demonstrate active listening or empathy and may not encourage the patient to open up further about their concerns.

A. Avoid assisting the patient to walk if they are restless. B. Discourage the family from staying with the patient. C. Move the patient to a room farther away from the nurses station. D. Ask the family what movies or music the patient would enjoy and offer them.

Correct Answer is D

Explanation

Choice A rationale:

Avoiding assisting a restless patient to walk does not address the issue of patient confusion and the risk of falling. Restless patients might need assistance, and refusing to help them walk could lead to further complications or falls.

Choice B rationale:

Discouraging the family from staying with the patient does not promote patient safety. Family members can provide additional support and supervision, reducing the risk of falls for a confused patient.

Choice C rationale:

Moving the patient farther away from the nurses' station does not address the patient's confusion or the risk of falling. It might even increase the response time in case of an emergency.

Choice D rationale:

Asking the family about the patient's preferences for movies or music and offering these activities is an appropriate way to engage the patient without resorting to restraints. Providing stimulating and enjoyable activities can help distract and calm the patient, reducing restlessness and the risk of falls.

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What actions taken by a newly licensed nurse are appropriate when documenting on paper? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient is upset, crying, and mumbles something about her job, but the nurse doesn't hear what the patient said about her job.What is the nurse's best response?

Correct Answer is A

Explanation

The nursing staff are caring for a confused patient who is at risk for falling.What action by the nurse would be appropriate in order to avoid restraining the patient?

Correct Answer is D

Explanation

A nurse delegates a specific intervention to unlicensed assistive personnel (UAP). What implications does this have for the nurse?

The nurse is caring for a client who is in the final stages of cancer, is depressed and distant.The client asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

The nurse performs range of motion by moving the patient's leg toward the midline of the patient's body.This movement would be documented as what of the hip?

A nurse uses the SBAR method to give report about a patient to another unit in the hospital.What statement by the nurse would the nurse identify as the "situation" portion of the SBAR report?

The nurse explains isometric exercises to the patient on the rehabilitation unit.Which explanation provided by the nurse is accurate?

The nurse is implementing interventions to reduce the number of falls in the health care facility.What action is best for the nurse to implement?

The nurse is teaching the client to use an incentive spirometer.What would the nurse include in the teaching plan?