A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

Includes quotes from the client

Remains logged in to the charting system throughout the shift

Makes reference in the nurses notes of completing an incident report

Documents that the provider wrote an inaccurate prescription

Answer and Explanation

The Correct Answer is A

A) Includes quotes from the client:

Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.

B) Remains logged in to the charting system throughout the shift:

Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.

C) Makes reference in the nurse's notes of completing an incident report:

While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.

D) Documents that the provider wrote an inaccurate prescription:

Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.

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Correct Answer is D

Explanation

A) Place the client in a supine position:

Placing a client with pulmonary edema in a supine position can exacerbate symptoms by increasing venous return and worsening fluid accumulation in the lungs. Instead, positioning the client upright or in a semi-Fowler's position is more appropriate to facilitate respiratory mechanics and decrease venous return.

B) Weigh the client every other day:

Daily weight monitoring is crucial for clients with pulmonary edema to assess fluid balance accurately. Weighing the client every other day may not provide timely information on fluid retention and response to treatment. Therefore, daily weight measurement is typically recommended.

C) Encourage the client to ambulate three times per day:

While mobility is essential for overall health, clients with pulmonary edema may experience dyspnea and fatigue, limiting their ability to ambulate. Ambulation should be encouraged but should be tailored to the client's tolerance level and may need to be adjusted based on their respiratory status.

D) Report urine output less than 30 mL/hr:

Monitoring urine output is vital in clients with pulmonary edema to assess kidney perfusion and fluid balance. A urine output of less than 30 mL/hr may indicate decreased renal perfusion and impaired fluid clearance, which can exacerbate pulmonary congestion. Therefore, it is crucial to report such findings promptly for further evaluation and intervention.

A. "I respect your right to choose to discontinue treatment." B. "I will have a hospice nurse come discuss this kind of care with you. C. "I will answer any questions you have about hospice care honestly." D. "I work with hospice services to help you transition to their care."

Correct Answer is C

Explanation

A) "I respect your right to choose to discontinue treatment."

While this statement acknowledges the client's autonomy and right to make decisions about their care, it does not directly address the nurse's commitment to honesty or transparency in discussing hospice care.

B) "I will have a hospice nurse come discuss this kind of care with you."

While involving a hospice nurse is a supportive action, it does not directly demonstrate the nurse's commitment to honesty or openness in discussing hospice care with the client.

C) "I will answer any questions you have about hospice care honestly."

This statement demonstrates veracity by explicitly stating the nurse's commitment to providing truthful and accurate information about hospice care. It reassures the client that they can trust the nurse to provide honest answers to their questions.

D) "I work with hospice services to help you transition to their care."

While this statement indicates the nurse's involvement in facilitating the transition to hospice care, it does not specifically address the nurse's commitment to honesty or truthfulness in discussing hospice care with the client.

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