The charge nurse is evaluating patient documentation of a new staff nurse. Based on which of the following does the charge nurse note, on review of the new nurse's charting, that appropriate documentation is evident?
a. A pencil was used to make the entries.
b. Correction fluid was used to correct written errors.
c. An error made by the attending physician was documented.
d. All of the entries he or she made in the record were dated and signed.
D
Feedback
A All entries should be recorded legibly and in black ink, because pencil can be erased.
B 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 might appear as if the nurse were attempting to hide something or deface the record.
C If the physician made an error, the nurse should not document it in the patient's chart; the error should be documented in an incident report.
D Each entry should begin with the time of entry and end with the signature and title of the nurse who recorded the entry.
You might also like to view...
While reviewing the bones in anatomy class, the instructor discusses this type of bone that protects the underlying structures. A good example of a flat bone is:
A) metatarsal bones. B) vertebrae. C) femur. D) skull.
A client has interstitial cystitis and has had several treatments with instillation of oxychlorosene (Clorpactin) into the bladder. The client is crying and verbalizing frustration with the frequent treatments that seem to do no good
The best response by the nurse is a. "Do you get upset easily with other problems?" b. "I'm concerned that this doesn't seem to be helping you." c. "Let's ask the doctor when you can expect to see some results." d. "You seem upset. I can sit with you for a few minutes."
When assessing the body alignment of a patient while he or she is standing, the nurse is aware that
a. When observed posteriorly, the hips and shoulders form an "S" pattern. b. When observed laterally, the spinal curves align in a reversed "S" pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out.
The client states that an herbal supplement is "better" because it is standardized. What is the nurse's best response regarding standardization?
1. It shows which products were tested for their efficacy. 2. It shows which supplements underwent clinical trials. 3. It allows for a comparison of potency among herbal products. 4. It indicates which products are FDA-approved.