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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Return demonstration involves the client demonstrating the skill back to the nurse after instruction, ensuring understanding and competence.
B. Discussion involves exchanging information verbally but does not involve demonstration of skill.
C. Question and answer involves the nurse answering client questions but does not include a practical demonstration.
D. Role play involves acting out scenarios but may not directly involve the client performing the actual procedure.
Correct Answer is C
Explanation
A. Decreased temperature is a symptom of hypothyroidism, not hyperthyroidism which would indicate an overdose of levothyroxine.
B. Weight gain is more commonly associated with hypothyroidism, not hyperthyroidism caused by an overdose of levothyroxine.
C. Tachycardia (rapid heart rate) is a classic sign of hyperthyroidism, which can occur if the client's dose of levothyroxine is too high.
D. Bradypnea (slow breathing) is not typically associated with thyroid hormone overdosage.
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