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 B
Explanation
Answer and explanation
The correct answer is Choice B.
Choice A rationale
Speculating about the cause of the fall ("probably urinated on the floor") is unprofessional and lacks factual basis. Charting should be objective and based on observed facts, not assumptions.
Choice B rationale
Documenting objective observations, such as finding the patient on the floor with the urinal nearby, provides a factual account of the incident without making assumptions or assigning blame. This allows for a more accurate analysis of potential contributing factors.
Choice C rationale
Commenting on the nurse assistant's work habits ("always took her time") is subjective, irrelevant to the fall incident itself, and unprofessional. Charting should focus on the patient and the event.
Choice D rationale
Describing the patient as "grouchy and inappropriate" is judgmental, subjective, and does not contribute to an understanding of the fall. Such personal opinions are inappropriate for medical documentation.
Correct Answer is C
Explanation
Choice A rationale
This is a closed-ended question that requires a yes or no answer. While it gathers specific information about breathing difficulty, it limits the patient's ability to describe their chest pain experience in their own words and provide richer details.
Choice B rationale
This question focuses on the duration of the chest pain. While this is important information for the nurse to know, it does not elicit a description of the pain itself, which is crucial for understanding the potential underlying cause and guiding further assessment.
Choice C rationale
This open-ended question encourages the patient to describe the characteristics of their chest pain, such as its quality (e.g., sharp, dull, crushing), location, radiation, and intensity. This detailed information is vital for differentiating between various causes of chest pain, including cardiac, musculoskeletal, or gastrointestinal issues.
Choice D rationale
While family history is relevant to the patient's overall health status and potential risk factors for certain conditions like heart disease, it does not directly address the patient's immediate experience of chest pain or provide details about the current symptom.
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