A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?

Black out the line with a felt-tip pen

Draw a horizontal line through the space and sign at the end of the line

Place the date at the beginning of the space, followed by double lines

Leave the space as it is within the entry

Answer and Explanation

The Correct Answer is B

A. Black out the line with a felt-tip pen: Blacking out a space or entry is inappropriate because it obscures the original documentation, making the record appear altered or falsified. Medical documentation must remain clear, transparent, and legally defensible at all times.

B. Draw a horizontal line through the space and sign at the end of the line: Drawing a single horizontal line through the blank space ensures that no unauthorized additions can be made later. Signing at the end of the line maintains the integrity and completeness of the medical record, following accepted documentation standards.

C. Place the date at the beginning of the space, followed by double lines: Simply dating the space without properly securing it with a line could leave it open to later insertions. Double lines are also not a recognized standard method for handling blank spaces in documentation.

D. Leave the space as it is within the entry: Leaving a blank space unmarked can create opportunities for someone to add unauthorized information later. This poses legal and ethical risks and compromises the reliability and security of the medical record.

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Correct Answer is A

Explanation

A. Handling cat feces: Toxoplasmosis is most commonly transmitted through exposure to Toxoplasma gondii, a parasite found in cat feces. Handling contaminated litter, soil, or sand without proper hygiene can lead to infection, making this the correct response.

B. Drinking contaminated water: While contaminated water can transmit various infections, toxoplasmosis is primarily associated with exposure to cat feces or undercooked meat, not typically with drinking water.

C. Eating shellfish: Eating shellfish can expose individuals to other types of infections, such as hepatitis A or certain bacterial infections, but it is not a known source of toxoplasmosis.

D. Touching body fluids: Toxoplasmosis is not spread through casual contact with body fluids like saliva, blood, or urine. It is mainly transmitted through ingestion of the parasite from contaminated sources.

A. "I really wish I had a girl instead." B. "I am so relieved the baby looks like my mother." C. "My labor was so long I'm glad it's over." D. "My appetite has really increased”

Correct Answer is A

Explanation

A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.

B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.

C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.

D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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