A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?

"Documentation of sensitive material is performed by the charge nurse."

You will be given access to the medical records of every client in the facility.

You will be asked to change your password once per year.

"Information Technology will install a firewall to secure client information."

Answer and Explanation

The Correct Answer is D

A. Incorrect. Documentation of sensitive material might have designated personnel, but this information does not need to be limited to the charge nurse.

B. Incorrect. Access to medical records should be limited to those with a need for that information, not every nurse in the facility.

C. Incorrect. Most facilities require more frequent password changes (e.g., every 90 days) to enhance security. Therefore, this statement may be inaccurate depending on the facility's policy.

D. Correct. Firewalls are security systems that are used to protect computer networks from unauthorized access. They are an important component of any computerized documentation system.

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Correct Answer is A

Explanation

A. Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.

B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.

C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.

D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.

A. Constipation B. Euphoria C. Bradypnea D. Sedation

Correct Answer is C

Explanation

A. Constipation is a potential side effect of morphine, but it is not the priority concern in this scenario.
B. Euphoria is a potential side effect of morphine but is not as immediately concerning as bradypnea.
C. Correct. Bradypnea (slow breathing) is a potential adverse effect of morphine and can lead to respiratory depression, which is a serious concern.
D. Sedation is an expected side effect of morphine, but the priority concern is the possibility of respiratory depression.

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A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?

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