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 B
Explanation
A. Mixing medication in a bottle with formula increases the risk of the infant not receiving the full dose and does not address the aspiration risk.
B. Administering medication with a needleless syringe placed in the buccal pouch allows for controlled, slow administration, minimizing the risk of aspiration.
C. Holding the infant in a supine position after administration is not sufficient to prevent aspiration during administration.
D. Administering medication quickly while the infant is restrained may increase the risk of aspiration due to rapid swallowing.
Correct Answer is ["2"]
Explanation
To administer the correct dose of aspirin, the nurse needs to calculate the number of 325 mg tablets that would equal the prescribed 650 mg dose. By dividing the prescribed dose (650 mg) by the strength of the available tablets (325 mg), we find that it equals exactly 2.
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