Evidence that a nurse adheres to practice guidelines that result in documentation that meets legal and ethical standards is shown when:
1. Charting the client's response to pain medication taken.
2. Describing the client as "appearing to be comfortable."
3. Leaving sufficient charting space for the previous shift to chart client teaching.
4. Documenting that the client reports, "I'm so afraid of tomorrow's surgery."
5. Making a late entry regarding a client's request for pain medication.
Correct Answer: 1,4,5
Rationale 1: Documentation guidelines include charting a change in a client's condition and showing that follow-up actions were taken.
Rationale 2: Documentation guidelines include not using vague terms (e.g., "appears to be comfortable").
Rationale 3: Documentation guidelines include not leaving a blank space for a colleague to chart later.
Rationale 4: Documentation guidelines include recording the client's actual words by putting quotation marks around the words.
Rationale 5: Documentation guidelines include the idea that a late entry is better than no entry.
Global Rationale:
You might also like to view...
A patient presents to the CCU with acute, decompensated heart failure. The nurse observes that this patient has chronic obstructive pulmonary disease and hypotension. She eats a low-sodium diet and drinks alcohol excessively
Which of the following are contributing factors to this patient's heart failure? Select all that apply. A) Chronic obstructive pulmonary disease B) Hypotension C) Low-sodium diet D) Excessive alcohol intake
The patient is admitted for IV administration of antifungal medication with the plan to discharge the patient on oral medication in a few days. What medication would the nurse be able to administer both IV and orally?
A) Fluconazole B) Itraconazole C) Posaconazole D) Terbinafine
The liver performs numerous functions that contribute to homeostasis, including the synthesis of bile. How is bile utilized in the processes of digestion and absorption?
A) Bile is produced in the liver in response to meals that are high in protein. B) Bile is stored in the gallbladder until it is needed for carbohydrate metabolism. C) Bile is produced in the liver but released by the gallbladder when needed for digesting fats. D) Bile production increases when an individual's fat intake is reduced over several days.
A nurse is overhead saying, "I don't mind working during the election and holiday. My parents are divorced, money is tight, and honestly I don't trust any politicians anyway. I plan to take a few weeks off next month."
She works independently to research strategies to improve patient-centered care for the large number of immigrants that arrived in the area and then works with the team to share ideas. She recommends, "Let's think the suggestions over and come back together next week." This nurse's communication style is consistent with which generation? a. Baby boomers b. Traditionalist c. Generation X d. Millenniums