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 A

Explanation

A) Perform CPR on the client:

Performing CPR is a critical intervention during cardiac arrest to maintain circulation and oxygenation. Assistive personnel are trained in basic CPR techniques and can effectively administer chest compressions according to established protocols. Assigning this task to assistive personnel allows the nurse to focus on other aspects of resuscitation and coordination of care.

B) Assist with airway intubation:

Airway intubation requires specialized training and skills, typically performed by licensed healthcare providers such as nurses or physicians. While assistive personnel may assist with preparing equipment or positioning the client, they are not trained to perform airway intubation procedures.

C) Place defibrillator pads on the client:

Placing defibrillator pads requires knowledge of proper positioning and electrode placement to deliver effective defibrillation shocks. This task is typically performed by healthcare providers with training in advanced cardiac life support (ACLS). Assistive personnel may assist with tasks such as preparing the client's chest and clearing the area for defibrillation, but they do not typically apply the pads themselves.

D) Maintain IV access:

Maintaining IV access involves monitoring the IV site, adjusting flow rates, and administering medications or fluids as ordered. While assistive personnel may assist with tasks related to IV access, such as holding the IV bag or adjusting tubing, they are not typically responsible for the overall management and maintenance of IV access during a cardiac arrest situation.

A. Reinforcing teaching with a client about stool specimen collection B. Collecting a urine specimen from a client who is experiencing dysuria C. Taking the vital signs of a client who is experiencing acute angina D. Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure

Correct Answer is B

Explanation

A) Reinforcing teaching with a client about stool specimen collection:

This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.

B) Collecting a urine specimen from a client who is experiencing dysuria:

Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.

C) Taking the vital signs of a client who is experiencing acute angina:

Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.

D) Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure:

Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.

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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?

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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