When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
Signing on with a password.
Charting in privacy.
Logging off.
Charting in code.
The Correct Answer is C
Choice A rationale
Signing on with a password authenticates the user and allows them to enter information, but it does not prevent someone with the same password or unauthorized access from altering previously entered data. Passwords control who can access the system, not what they can do once logged in.
Choice B rationale
Charting in privacy ensures confidentiality while the nurse is documenting, preventing unauthorized individuals from viewing the information as it is being entered. However, it does not prevent authorized users from later altering the data.
Choice C rationale
Logging off the electronic documentation system after each entry is crucial for preventing unauthorized access and alterations. Once logged off, the nurse's session is closed, requiring a new login to make any changes, thus ensuring accountability for each entry.
Choice D rationale
Charting in code or using abbreviations can help maintain patient privacy to some extent but does not inherently prevent alteration of the information once it has been entered into the system. Codes can be understood by those with access. \
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Subjective opinions like "pleasant to care for" lack specific, objective data about the patient's condition or care provided. Medical documentation should focus on factual observations and interventions related to the patient's health status.
Choice B rationale
"Voiding without difficulty" is a relevant observation regarding the patient's urinary function. However, it lacks specific details such as the amount, color, or clarity of the urine, which are important for a comprehensive assessment.
Choice C rationale
This statement provides specific and objective information about the patient's pain experience. It includes the patient's self-reported pain level (6/10), the location of the pain (left temporal area), and a relevant negative finding (no relief with positioning), all contributing to a clear understanding of the patient's condition.
Choice D rationale
"Onsite looks good" is vague and lacks specific details about the condition of a particular site (e.g., surgical wound, IV insertion site). Effective documentation requires descriptive terms regarding appearance, such as color, presence of drainage, swelling, or redness.
Correct Answer is A
Explanation
Choice A rationale
AC and HS is a common abbreviation in medical orders that stands for "ante cibum" (before meals) and "hora somni" (at bedtime). Therefore, "ambulate patient four times a day AC & HS" means the patient should ambulate before breakfast, before lunch, before dinner, and at bedtime.
Choice B rationale
NG is an abbreviation for nasogastric, which refers to a tube inserted through the nose into the stomach and is not related to ambulation orders.
Choice C rationale
DNR stands for "do not resuscitate," which is a medical order regarding end-of-life care and is not related to ambulation.
Choice D rationale
STAT is an abbreviation meaning "immediately" and is typically used for urgent medications or treatments, not for routine ambulation orders.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.