When documenting events in a patient's chart, the nurse should chart:
the specific time of all sudden changes in the patient's condition
the period the shift covers
every 2 hours
every hour on the hour
The Correct Answer is A
A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.
B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.
C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.
D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Signs of fluid overload: Fluid overload presents with edema, crackles in lungs, and increased blood pressure, not dry skin and mucous membranes.
B. Symptoms: Symptoms are subjective (e.g., pain, nausea), while the given findings are observable signs.
C. Data clustering: The nurse groups related signs (flushed skin, dry mucous membranes, elevated temperature) to identify a pattern suggesting dehydration or fever.
D. Urinary retention: Urinary retention is associated with bladder distention and reduced urine output, not dry skin and mucous membranes.
Correct Answer is C
Explanation
A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.
B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.
C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.
D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.
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