A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.
Document and describe interventions performed by the previous shift nurse.
Use standard terminology and commonly used medical abbreviations.
Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.
Do not document nursing interventions ahead of time before performing them.
Document nursing interventions performed by the nurse who is documenting.
Correct Answer : B,C,D,E
correct answers are:
B Use standard terminology and commonly used medical abbreviations.
C Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.
D o not document nursing interventions ahead of time before performing them.
E Document nursing interventions performed by the nurse who is documenting.
Nurses play a crucial role in patient care and documentation guidelines are important to ensure accuracy, completeness, and continuity of care. Using standard terminology and commonly used medical abbreviations is important to ensure that documentation is clear, concise, and easily understood by all members of the healthcare team. This practice helps avoid confusion, facilitates communication, and ensures that all healthcare professionals can accurately interpret and act upon the documented information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["333"]
Explanation
To calculate the infusion rate, we need to divide the total volume to be infused by the total time of infusion and then multiply by 60 to convert to mL/h:
1000 mL ÷ 3 hours = 333.33 mL/h
Rounding to the nearest whole number, the IV pump should be programmed for 333 mL/h.
Correct Answer is C
Explanation
The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.
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