The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

the insulin was administered based per the nurse's testimony

none of the answers are correct

the insulin was administered based on the witness testimony

the insulin was not administered because it was not charted

Answer and Explanation

The Correct Answer is D

A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.

B. None of the answers are correct: One of the answers is correct based on legal documentation principles.

C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.

D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.

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Correct Answer is C

Explanation

A. Omission exists: An omission means something was left out, but that does not fully explain why the projected outcome was not met.

B. Failure exists: The term failure is not a standard term in critical pathways. The situation could be due to various factors beyond "failure."

C. Variance exists: A variance occurs when the patient’s progress deviates from the expected outcome within a critical pathway. This can be positive (faster recovery) or negative (delay in progress).

D. Error exists: A variance is not necessarily an error, as some patients may require longer recovery times due to medical conditions.

A. not used by anyone else but the direct care providers B. concise, legal records of all care given and responses C. owned by the patient, who has a right to see the data any time he/she wishes D. confidential information and cannot be taken to court

Correct Answer is B

Explanation

A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.

B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.

C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.

D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.

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The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

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Naxlex Comprehensive Predictor Exams

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an:

Correct Answer is C

Explanation

Patient health care records are:

Correct Answer is B

Explanation

When using the SOAP method of charting, S stands for subjective data which means:

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

In which step of the nursing process do nurses look at outcomes?

On what form/forms should the nurse chart when administering a narcotic?

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

To what does objective data refer when assessing a patient?