A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse. Which of the following should the charge nurse include in the teaching? (select all that apply)
A medical record can be used as evidence in a court of law
A nurse should ensure the documentation is organized and completed in a timely fashion
Documentation should include the nurse's interpretation of the client situation
Data contained in a client's medical record can be shared with all employees within a health care facility
Information recorded in the client's medical record must be accurate and complete.
Correct Answer : A,B,E
A. A medical record can indeed be used as evidence in a court of law to support or refute claims related to patient care.
B. Documentation should be organized and timely to ensure accuracy and continuity of care.
C. Documentation should not include the nurse's interpretation but rather objective data and actions taken.
D. Data in a client's medical record should only be shared with those directly involved in the client's care unless otherwise authorized.
E. Information recorded in the client's medical record must be accurate and complete to support safe and effective client care and legal purposes.
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Correct Answer is C
Explanation
A. Lecture involves one-way communication where information is delivered by the nurse to the client without active participation. It does not confirm understanding or assess learning through client feedback.
B. Question and answer involves the nurse posing questions to assess understanding but may not actively involve the client in demonstrating knowledge or skills.
C. Teach-back is an effective teaching method where the nurse asks the client to explain the procedure back in their own words. This technique helps assess the client's understanding, clarify information, and reinforce learning, promoting patient empowerment and adherence to treatment plans.
D. Role play involves simulating scenarios to practice skills or behaviors, which may not directly assess the client's understanding of a specific procedure.
Correct Answer is B
Explanation
A. Sublingual medications are meant to be absorbed under the tongue and should not be administered through an NG tube, which bypasses this route of absorption.
B. Administering the medication under the tongue is the correct route for sublingual administration. It ensures that the medication is allowed to dissolve completely and is not swallowed immediately. This allows for the intended rapid absorption through the sublingual route.
C. If a client has an NG tube and needs a medication that is typically given sublingually, the nurse should administer the medication under the tongue.
D. Dissolving sublingual medication in water for NG tube administration is not appropriate as it alters the intended route of absorption.
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