After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
Enter the occurrence after the 1400 notes and identify as "late entry".
Request removal initiated by the Health Information Manager.
Create an electronic correction after 1400 notes are officially unlocked.
Make an electronic addendum following the 1400 documentation.
The Correct Answer is D
A. Enter the occurrence after the 1400 notes and identify as "late entry":
While entering the occurrence after the 1400 notes is an option, labeling it as a "late entry" may not provide sufficient clarity regarding the timing of the documentation. Using a "late entry" label could potentially lead to confusion or misinterpretation.
B. Request removal initiated by the Health Information Manager:
Requesting removal of the 1400 notes by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.
C. Create an electronic correction after 1400 notes are officially unlocked:
Making an electronic correction implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.
D. Make an electronic addendum following the 1400 documentation:
An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It's important to ensure that the addendum clearly identifies the timing of the documentation to maintain accuracy and transparency in the medical record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Positive external places:
Guided imagery typically involves directing the client to visualize calming and peaceful external environments, such as a beach, forest, or other positive, serene places. This technique helps divert the client's attention away from pain and promotes relaxation.
B. Emotional reflection:
Emotional reflection may be part of the guided imagery process, especially if it helps the client process and cope with their emotions related to chronic pain. However, the primary focus of guided imagery is typically on visualization techniques rather than emotional reflection alone.
C. Motivational phrases:
Motivational phrases can be helpful in some relaxation techniques, but in guided imagery for chronic pain management, the emphasis is usually on visualizing soothing images or scenarios rather than repeating motivational phrases.
D. Tranquil sounds:
Tranquil sounds may be part of a relaxation strategy, but guided imagery specifically involves visualizing calming scenes, not just focusing on sounds.
Correct Answer is B
Explanation
A. Encourage the use of incontinence briefs:
While incontinence briefs may help contain fecal leakage and protect clothing and bedding, they do not address the underlying issue of fecal incontinence or assist the client in achieving continence. Additionally, relying solely on incontinence briefs may not promote independence or improve the client's quality of life.
B. Assist to a bedside commode 30 minutes after meals:
This is the most appropriate intervention for establishing a bowel training regimen. Timing the use of the bedside commode after meals takes advantage of the gastrocolic reflex, which increases bowel motility after eating. Assisting the client to the commode at specific intervals helps promote regular bowel movements and may decrease the likelihood of fecal incontinence episodes.
C. Administer a glycerin suppository 15 minutes after meals:
While glycerin suppositories can stimulate bowel movements, they are typically used for acute constipation rather than chronic fecal incontinence. Additionally, using suppositories does not address the client's emotional distress or help establish a bowel training regimen focused on promoting continence.
D. Insert a rectal tube at specified intervals:
Rectal tubes are not typically used as a first-line intervention for bowel training in clients with fecal incontinence. They may be indicated in certain situations, such as severe impaction or when other interventions have failed, but they are not appropriate for all clients and may cause discomfort and complications.
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