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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Related Questions
Correct Answer is C
Explanation
A. Determining the client's response to the medication is important but should occur after ensuring the safety of administering the medication.
B. Documenting medication administration is necessary but should follow the safe administration process.
C. Checking the client for allergies is the first step to ensure the client can safely receive the medication, preventing adverse reactions.
D. Mixing the medication at the client's bedside may be necessary for some medications but is not the initial step in ensuring safe administration.
Correct Answer is ["2"]
Explanation
To administer the correct dose of clonidine, which is 0.2 mg, and given that each tablet contains 0.1 mg of clonidine, the nurse would need to administer two tablets. This is because 0.2 mg divided by 0.1 mg per tablet equals 2 tablets.
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