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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Determine possible alternatives:
After identifying the ethical problem, determining possible alternatives comes later in the ethical reasoning process. This step involves brainstorming potential courses of action or solutions to address the ethical dilemma.
B) Examine the outcomes:
Examining the outcomes occurs after identifying possible alternatives. In this step, the nurse evaluates the potential consequences or outcomes of each alternative to determine which course of action aligns best with ethical principles and achieves the desired goals.
C) Develop a plan of action:
Developing a plan of action is a subsequent step in the ethical reasoning process, following the identification of the problem and consideration of possible alternatives. Once the nurse has evaluated the outcomes of various options, they can formulate a plan that outlines the chosen course of action and its implementation steps.
D) Identify the problem:
Identifying the problem is the first step in the ethical reasoning process. This involves recognizing the presence of an ethical dilemma or issue that requires resolution. By clearly defining the problem, the nurse can begin to explore relevant ethical principles, values, and considerations to guide decision-making and problem-solving.
Correct Answer is B
Explanation
A) Contact the nurse from the previous shift to report the doubled dose:
While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.
B) Document the doubled dose in the client's medical record:
Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.
C) Place a copy of the incident report in the client's record:
While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.
D) Report the incident to the manager of the pharmacy:
Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.
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