A nurse is documenting at a computer when a second nurse asks to use the computer to quickly document data before taking a break. Which of the following actions should the first nurse take?
Allow the second nurse to enter the data while observing them.
Log off the computer and let the second nurse log on and enter the data.
Ask the second nurse for the data and enter it for them
Tell the second nurse to enter the data when they return from their break.
The Correct Answer is B
A. Allow the second nurse to enter the data while observing them. Even if observed, allowing another person to use a computer while logged in under someone else’s credentials violates HIPAA and security policies.
B. Log off the computer and let the second nurse log on and enter the data. This is the correct and secure action. Each nurse must use their own login to ensure accountability and protect patient confidentiality, as required by HIPAA and institutional policies.
C. Ask the second nurse for the data and enter it for them. This may lead to documentation errors or confusion about who provided care. Each nurse should document their own assessments and interventions.
D. Tell the second nurse to enter the data when they return from their break. While delaying documentation is sometimes necessary, timely documentation is important for safe patient care. The second nurse should have the opportunity to chart promptly, but under their own credentials.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Irrigate the wound using a 10-mL syringe. A 10-mL syringe does not provide adequate pressure for effective irrigation. Typically, a 30- to 60-mL syringe with an 18-gauge catheter is used to deliver appropriate pressure (between 4–15 psi) to clean wounds effectively.
B. Irrigate the wound with a low-pressure flow of solution. This is correct. A low-pressure irrigation system helps gently remove debris and bacteria without damaging healthy tissue. It also minimizes the risk of forcing contaminants deeper into the wound bed.
C. Cleanse the insertion site of the drain using a circular motion toward the center. The site should be cleansed from the center outward, not toward the center, to prevent dragging contaminants into the insertion site and reduce infection risk.
D. Cleanse the wound starting at the bottom and moving upward. Wound cleaning should occur from the least contaminated (top) to the most contaminated (bottom) area to avoid transferring microorganisms from dirtier areas to cleaner areas, thereby minimizing the risk of infection.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B,C"}}
Explanation
- Urticaria: Urticaria (hives) is a hallmark sign of an allergic reaction, particularly latex allergy, and typically appears quickly following exposure to allergens. It is not seen in malignant hyperthermia or hypovolemic shock.
- Wheezing: Wheezing can occur in latex allergy due to bronchospasm or airway edema. While respiratory compromise may happen in malignant hyperthermia, it is typically due to muscle breakdown and CO2 retention, not bronchospasm. Wheezing is not expected in hypovolemic shock.
- Muscle rigidity: Generalized rigidity, especially of the jaw (masseter spasm), is a key early sign of malignant hyperthermia, a life-threatening reaction to certain anesthetics. It is not a symptom of latex allergy or hypovolemic shock.
- Hypercapnia: An elevated PaCO₂ is an early, sensitive marker of malignant hyperthermia, resulting from increased CO₂ production due to sustained muscle contraction. This does not occur in latex allergy or hypovolemic shock.
- Tachycardia: Elevated heart rate can be seen in all three conditions: in malignant hyperthermia due to increased metabolic demand, in latex allergy due to anaphylactic reaction, and in hypovolemic shock as a compensatory response to fluid loss.
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