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.

Answer and Explanation

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 D

Explanation

A. Asking the patient to use the bathroom is unrelated to the administration of nasal spray and is not necessary.
B. Instructing the patient to look up at the ceiling is not required for nasal spray administration and does not facilitate the process.
C. Asking the patient to take a deep breath is not directly related to the administration of nasal spray and does not affect its effectiveness.
D. Asking the patient to blow his/her nose to clear the nasal passages is important before administering nasal spray. Clearing nasal passages helps ensure that the medication can reach the nasal mucosa effectively, improving absorption and efficacy of the spray.

A. At the time of documentation B. In the area where the nurse obtained the medication C. In the nurses' station while reviewing the provider's prescription D. At the client's bedside before administration

Correct Answer is D

Explanation

A. Performing the final medication check at the time of documentation may result in errors if there are discrepancies between the prescription and what is documented.
B. Checking the medication in the area where it was obtained may not ensure accuracy regarding patient identity, dose, or route before administration.
C. Reviewing the provider's prescription at the nurses' station is important but should not replace the final bedside check immediately before administration.
D. Performing the final medication check at the client's bedside ensures accuracy and patient safety by verifying the correct medication, dose, route, and patient identity directly before administration.

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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)

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Naxlex Comprehensive Predictor Exams

The patient is ordered a nasal spray. Which intervention should the nurse instruct the patient to do prior to administration of the nasal spray?

Correct Answer is D

Explanation

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?

Correct Answer is D

Explanation

A client is prescribed fluticasone, what complications or side effects should the nurse alert the client to?

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