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 B
Explanation
A. Begin the collection the next day:
This option would delay the start of the 24-hour urine collection unnecessarily. Since the client has already begun voiding, it's appropriate to start the collection process with the next void.
B. Start collecting the specimen with the next void:
Since the client has already provided a urine sample, the nurse should discard this initial void and begin the 24-hour collection process with the next void. This ensures that the entire 24-hour period is captured for accurate measurement of creatinine clearance.
C. Observe the sample for sediment:
While observing the sample for sediment may be part of the assessment process, it is not the priority in this situation. The focus should be on initiating the 24-hour urine collection process correctly.
D. Empty the sample into the 24-hour container:
The initial void should not be emptied into the 24-hour container, as this would inaccurately include urine that was not collected over the entire 24-hour period. It's important to start the collection process fresh with the next void to ensure accurate results for creatinine clearance measurement.
Correct Answer is A
Explanation
A. 1.035:
This specific gravity value indicates highly concentrated urine. In the context of a client experiencing vomiting, diarrhea, and difficulty tolerating oral fluids, such a high specific gravity would be indicative of significant dehydration. Dehydration occurs when the body loses more fluid than it takes in, leading to an imbalance in electrolytes and an increase in urine concentration.
B. 1.015:
This specific gravity value falls within the normal reference range for urine specific gravity. In the context of vomiting, diarrhea, and difficulty tolerating oral fluids, a value within the normal range may be less likely. However, it's important to note that initial testing may not reflect the full extent of dehydration, especially if the client's fluid intake has been severely limited over a short period.
C. 1.005:
This specific gravity value is at the lower end of the normal reference range for urine specific gravity. In a client experiencing significant fluid loss through vomiting and diarrhea, the urine may become more concentrated as the body attempts to conserve water. Therefore, a value of 1.005 would be less likely on initial testing in this context.
D. 1.025:
Similar to Option B, this specific gravity value falls within the normal reference range. While it's possible for a dehydrated individual to have a specific gravity within the normal range, a value of 1.025 may be less likely in the context of significant fluid loss through vomiting and diarrhea. However, it's important to consider that dehydration severity and urine concentration can vary among individuals.
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