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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Correct answer: C

A. Irrigate the nasogastric tube with water:

This option is not the best immediate action when a client is choking after vomiting. While irrigating the nasogastric tube with water may help clear the tube itself, it does not directly address the choking episode or potential airway obstruction. The priority in this situation is to ensure the client's airway is clear and maintain their safety.

B. Perform oropharyngeal suctioning:

While suctioning might be used later to clear the airway of secretions, it's not the first-line intervention when someone is actively choking. Suctioning can stimulate the gag reflex and worsen vomiting..

C. Elevate the head of bed 45 degrees:

The primary concern is preventing aspiration (inhaling vomit) which can lead to serious complications. Elevating the head of the bedhelps keep the head and neck in a position that promotes drainage of fluids and reduces the risk of aspiration.

D. Review the advance directive document:

Reviewing the advance directive document is important for understanding the client's wishes regarding their healthcare decisions, but it is not the appropriate action in the immediate management of a choking episode. Ensuring the client's safety and addressing the choking episode take precedence over reviewing documentation.

A. Withdraw the medication into a syringe and label it with the client's name. B. Throw the vial into the trash in the presence of another nurse. C. Place the vial with the remainder of the medication into a locked drawer. D. Ask another nurse to witness the medication being discarded.

Correct Answer is D

Explanation

A. Withdraw the medication into a syringe and label it with the client's name:

This is not necessary for the remainder of the medication. The medication should not be withdrawn into a syringe for future use or left labeled, as it could lead to errors or contamination.

B. Throw the vial into the trash in the presence of another nurse:

Discarding the vial into the trash is not appropriate, as it does not ensure proper documentation, accountability, or safe storage of the remaining medication. Additionally, the presence of another nurse does not address these concerns.

C. Place the vial with the remainder of the medication into a locked drawer:

While storing the vial in a locked drawer may prevent unauthorized access, it does not address the need for proper documentation and labeling of the remaining medication. Additionally, the vial should not be stored with the medication still in it after withdrawal.

D. Ask another nurse to witness the medication being discarded:

This is the appropriate action. Many facilities require that the disposal of unused or remaining medications, especially controlled substances, be witnessed by another nurse to ensure accountability and compliance with regulations.

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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?

Nursing Test Bank

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