A nurse is documenting in a client's electronic medical record. Which of the following entries should the nurse use?

Ativan 1 mg IV given at 1030 following OR call

Acetaminophen 500 mg given for pain

MgSO4 infusing via IV pump

Insulin 5U administered SQ

Answer and Explanation

The Correct Answer is A

A. Ativan 1 mg IV given at 1030 following OR call. This is correct. The entry is clear and includes the medication name, dose, route, and time of administration.
B. Acetaminophen 500 mg given for pain. The entry does not specify the route of administration or the time it was given.
C. MgSO4 infusing via IV pump: This is incorrect. Abbreviations like "MgSO4" can be confusing or misinterpreted. It should be written as "magnesium sulfate."
D. Insulin 5U administered SQ: This is incorrect. The entry uses the abbreviation "U" for units, which can be misinterpreted. It should be written as "units" and specify the exact time and site of administration.

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Correct Answer is D

Explanation

A. Provide information about the risks of a surgical procedure to the client. Providing risk information is part of informed consent, not specifically part of Universal Protocol.
B. Request the client sign the informed consent form after administering a preoperative sedative. Informed consent should be obtained before administering sedatives to ensure the client is fully aware and able to consent.
C. Mark the client's surgical site with a small strip of nonporous tape. The surgical site should be marked with a permanent marker to ensure it remains visible and clear throughout the surgical preparation and procedure.
D. Call a "time out" to verify client identity before starting a surgical procedure. This is correct. The Universal Protocol includes a "time out" to verify the correct patient, procedure, and site before starting the surgery.

A. "Ask the charge nurse if she will enter the vital signs for you." B. "I'll give you my password to use on another computer, but only for those vital signs." C. "I can't let you use the computer on my login, but give me the vital signs and I'll enter them." D. "Contact the information technology team and ask them to reset your password."

Correct Answer is C

Explanation

A. "Ask the charge nurse if she will enter the vital signs for you." This option might be practical but does not address the issue of ensuring proper use of login credentials and adherence to privacy and security protocols.
B. "I'll give you my password to use on another computer, but only for those vital signs." Sharing passwords is a violation of security protocols and is not permissible. Each user must use their own credentials to ensure accountability and security.
C. "I can't let you use the computer on my login, but give me the vital signs and I'll enter them." This response is appropriate. It maintains security by not sharing passwords while still addressing the immediate need of entering the vital signs.
D. "Contact the information technology team and ask them to reset your password." While contacting IT for a password reset is a good practice, it doesn't solve the immediate problem of entering the vital signs. However, it is an important step for addressing long-term access issues.

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A nurse is documenting in a client's electronic medical record. Which of the following entries should the nurse use?

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Naxlex Comprehensive Predictor Exams

A nurse manager is developing an in-service about The Joint Commission's National Patient Safety Goals for a group of surgical nurses. Which of the following information regarding Universal Protocol should the nurse include in the in-service?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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