The charge nurse is evaluating the documentation of the new staff nurse. Based on which of the following does the charge nurse note, on review of the charting, that appropriate documentation is evident?
a. The new staff nurse used a pencil to make the entries.
b. The new staff nurse used correction fluid to correct written errors.
c. The new staff nurse identified an error made by the attending physician.
d. The new staff nurse has dated and signed all of the entries he or she made in the record.
D
Each entry should begin with the time of entry and end with the signature and title of the nurse who recorded the entry.
All entries should be recorded legibly and in black ink because pencil can be erased.
The nurse should never erase entries or use correction fluid, and never use a pencil. The use of correction fluid could render the charting illegible, and it may appear as if the nurse were at-tempting to hide something or deface the record.
If the physician made an error, the nurse should not document it in the client's chart; the error should be documented in an incident report.
You might also like to view...
According to the Masters and Johnson model, which best describes the pattern of the human sexual response cycle?
1. Linear 2. Nonlinear 3. Cluster 4. Gap
Which side effect is caused by selective alpha-1 blockers for benign prostatic hyperplasia?
a. Low blood pressure b. Male-pattern baldness c. Erectile dysfunction d. Urinary retention
Which statement about adenocarcinoma of the lung is accurate?
a. It is the least common type of lung cancer, representing approximately 5% to 10% of cases. b. It is the most prevalent carcinoma of the lung in both sexes and in nonsmokers, representing 35% to 40% of all tumors. c. It is more common in men than in women and occurs almost entirely in cigarette smokers. d. It is aggressive, with rapid growth and early local and distant metastases via the lymphatic and blood vessels.
Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder?
A. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and whispers, "The night nurse is evil. You have to stay." B. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and states, "I will be up all night if you don't stay with me." C. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm, yelling, "Please don't go! I can't sleep without you being here." D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."