A nurse manager is teaching a newly licensed nurse about documenting information in a client's medical record. Which of the following entries by the newly licensed nurse indicates an understanding of the teaching?
"The client is uncooperative and refused to take their morning medication."
"A 2 centimeter by 2 centimeter amount of purulent drainage was noted during a dressing change."
"A medication error was made on a previous shift. The client's vital signs are stable."
"The client was administered 4 units of regular insulin."
The Correct Answer is B
Choice A reason: Documenting that a client is "uncooperative" is subjective and judgmental. Medical records should contain objective, factual information rather than personal opinions or interpretations. This entry does not meet professional standards of documentation.
Choice B reason: Documenting the exact size and description of purulent drainage is objective, measurable, and factual. This entry provides clear clinical data that can be used for ongoing assessment and treatment planning. It avoids judgmental language and adheres to proper documentation standards. This makes it the correct answer.
Choice C reason: Documenting a medication error from a previous shift is inappropriate because nurses should only document events that occurred during their own shift. Errors should be reported through incident reporting systems, not in the client’s medical record. Including this information in the chart is incorrect.
Choice D reason: While documenting medication administration is appropriate, this entry is incomplete because it lacks essential details such as the route, time, and site of administration. Proper documentation requires comprehensive information to ensure continuity of care and safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "SQ q AM and q HS" is incorrect because it specifies morning and bedtime administration rather than every 12 hours. This could lead to dosing errors.
Choice B reason: "Enoxaparin 30 mg subcut every 12 hr" is the correct documentation. It uses standard terminology, specifies the correct dose, route, and frequency, and avoids abbreviations that could be misinterpreted.
Choice C reason: "30 mcg" is incorrect because it changes the dosage from milligrams to micrograms, which is a thousand-fold difference. This would result in a dangerous underdose.
Choice D reason: "sub q every AM and HS" is incorrect because it specifies administration twice daily at morning and bedtime rather than strictly every 12 hours. This could cause uneven dosing intervals.
Correct Answer is C
Explanation
Choice A reason: Ambulation promotes peristalsis and reduces postoperative complications, but it should not be encouraged before assessing the underlying cause of nausea and pain. Without assessment, ambulation could worsen discomfort or mask complications.
Choice B reason: Inserting an NG tube is an invasive intervention reserved for confirmed cases of bowel obstruction or severe ileus. Performing this without assessment risks unnecessary trauma and patient distress.
Choice C reason: Auscultating for bowel sounds is the priority because it provides critical information about gastrointestinal motility and potential complications such as ileus or obstruction. Assessment must precede interventions to ensure safety and appropriateness of care.
Choice D reason: Administering an antiemetic addresses symptoms but not the underlying cause. Symptom relief without assessment could delay recognition of serious complications.
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