The laboratory notifies the nursing unit that a substantial amount of test data was mistakenly recorded on the wrong patient's medical record two days ago. Who has the authority to alter the patient's record?
1. Anyone with access to the chart who had time to do so
2. Only administrative staff or the patient's primary physician
3. Only laboratory technicians or nurses who care for the patient
4. No one can correct the error; it is a part of the permanent record.
2
Rationale: When substantial errors occur such as incorrect test data, omitted progress notes, or incorrect orders, administrative staff and the primary physician can correct the error. This is to ensure a truthful and accurate record and to ensure that any necessary changes can be made to the current care of the patient. Allowing anyone or just one discipline to correct the error would lead to possible problems in patient care as it would if the error was left uncorrected.
You might also like to view...
What should be included in the nurse's teaching for a patient prescribed phenytoin (Dilantin) to control seizures?
a. "You may experience shortness of breath as a side effect of the drug." b. "You may notice some vision changes while taking this drug." c. "Be sure to brush and floss your teeth daily." d. "Be sure to arrange for regular checkups for potassium levels."
The student nurse is preparing a care plan for an assigned client. When writing the nursing diagnose for this client, which elements are required?
Select all that apply. 1. Medical diagnosis. 2. Risk or related factors. 3. Defining characteristics. 4. A diagnostic label. 5. A definition.
You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with the following report
Dr. Smith, I'm calling about Mrs. P., your 65-year-old patient in CCU 10 . Her urine output for the past 2 hours totaled only 40 mL. She arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour. Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient's history and vital signs is: a. Situation b. Background c. Assessment d. Recommendation
The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? Select all that apply
1. Position the hand at heart level. 2. Stroke the vein. 3. Have the client clench and unclench the fist. 4. Slap the back of the client's hand. 5. Massage the vein.