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) Place the client close to the nurses' station:

While placing the client closer to the nurses' station may enhance supervision and monitoring, it does not address the immediate safety concern of preventing the client from removing the IV catheter again. This action may be considered after implementing measures to prevent further self-harm.

B) Cover the site with a stockinette dressing:

Covering the site with a dressing is important for maintaining a sterile environment around the IV site. However, if the client is disoriented and has already removed the IV catheter, simply covering the site may not prevent further attempts to remove it. Addressing the underlying issue of the client's behavior is necessary.

C) Administer a sedative:

Administering a sedative may be appropriate in certain situations to calm an agitated or disoriented client. However, it should not be the first action taken after observing the reinsertion of the IV catheter. Sedation should be used judiciously and only after other interventions to ensure the client's safety have been attempted.

D) Apply a soft mitten restraint:

This is the most appropriate action to prevent the client from removing the IV catheter again. A soft mitten restraint limits the client's ability to access the IV site while allowing some movement and comfort. It is a temporary measure to ensure the safety of the client and the integrity of the IV line until further assessment and interventions can be implemented.

A. Verify the medication name along with its intended purpose. B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day." C. Transcribe the medication name using the trade me. D. Remind the provider to countersign the prescription in 72 hr.

Correct Answer is A

Explanation

A. Verify the medication name along with its intended purpose.

Rationale:

Verifying the medication name along with its intended purpose is crucial to ensure accuracy and patient safety. In this scenario, the nurse should confirm that the medication name "propranolol" matches the intended medication prescribed by the provider. Additionally, understanding the purpose of the medication ensures that the nurse can correctly communicate this information to the patient, reinforcing patient education and adherence to the prescribed treatment plan. Verifying the medication name and purpose helps prevent medication errors and promotes safe medication administration practices.

B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day."

Verbalizing the letters "B-I-D" for the dosing frequency instead of saying "twice per day" is not the most appropriate action in this situation. While using medical abbreviations like "B-I-D" (which stands for "bis in die" or "twice a day") is common in healthcare settings, it's essential to ensure clear communication with all involved parties, including patients and providers. Using layman's terms like "twice per day" helps avoid confusion and promotes better understanding, reducing the risk of medication errors due to misinterpretation.

C. Transcribe the medication name using the trade name.

Transcribing the medication name using the trade name is not appropriate unless specifically instructed by the provider or if there is a specific reason to do so. In this scenario, the nurse should use the generic name "propranolol" when transcribing the medication to ensure consistency and accuracy in documentation and communication. Using trade names can lead to confusion, especially in environments where multiple brand names may exist for the same generic medication.

D. Remind the provider to countersign the prescription in 72 hr.

Reminding the provider to countersign the prescription in 72 hours is not relevant to the immediate task of verifying and reading back the prescription information. While ensuring proper documentation and authorization of prescriptions is important, it should not be addressed during the initial verification and communication process. This action can be addressed separately, following the completion of the prescription verification process.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider. which of the following actions should the nurse take?

Correct Answer is A

Explanation

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