At 9:15 the nurse repeatedly instructs the client to remain in bed. At 9:30, the nurse enters the client's room, finds the client on the floor, and hears the client say, "I need pain medicine."
Which does the nurse use to document this event? 1. Labels the late entry using the time of 9:15
2. Encloses client statement within quotations
3. Documents completion of an incident report
4. Records medication before its administration
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2. The nurse encloses client statements within quotations to indicate the client's pre-cise statement. This is preferable to paraphrasing someone's statement because pa-raphrasing can change the meaning.
1. To record a late entry, the nurse documents using the time at the documentation and includes the time of the occurrence and the label "late entry.". A late entry is not indicated for this documentation; so, the nurse should document the instructions giv-en at 9:15 and verify client understanding if the client indicated understanding at "9:15" on the medical record and document the events occurring at 9:30 at "9:30" on the medical record.
3. The nurse avoids documenting the completion of an incident report on the client's medical record to prevent its discovery in a legal proceeding.
4. The nurse records medications after administration because entries document actual events; if the client refuses the medication or the medication becomes unusable, the documentation becomes false.
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Critical thought is:
a. a disciplined, rational, and self-directed activity that uses standards and criteria. b. an intuitive process that relies only on the nurse's experience. c. a persuasive process leading to sound decisions. d. a reactive process after an intervention is completed.
When the nurse is evaluating the effectiveness of nursing interventions, which of the following is done?
a. Comparing nursing diagnoses to goals and outcomes b. Comparing nursing diagnoses to medical diagnoses c. Comparing goals and outcomes to client's progress d. Comparing medical orders to client vital signs data
The nurse volunteers services at a free medical clinic. What is true of these donated services?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. They fall under the auspices of the state nurse practice act. 2. Since the nurse is serving as a volunteer an exemption from possible lawsuit exists. 3. The nurse should practice as a reasonably prudent nurse when providing these services. 4. The nurse should assure that a system of record keeping is initiated and maintained. 5. The nurse's actions will be protected by Good Samaritan laws.
A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which of the following assessments would be most important prior to administering a new dose?
A) Blood pressure B) Patellar reflex C) Pulse rate D) Anxiety level