The nurse makes an error while documenting in the client's chart. The nurse should:

draw a straight line through the error with a black ink pen and initial it.

use a permanent marker to draw a line through the error and write "mistaken entry".

cover the mistake with correction fluid and skip a line.

erase the error and write the correct information.

Answer and Explanation

The Correct Answer is A

A. Draw a straight line through the error with a black ink pen and initial it: This is the correct action to take when making an error while documenting in the client's chart. Drawing a single line through the error with a black ink pen ensures that the original information remains visible for auditing purposes. The nurse should then write the correct information above or adjacent to the error, initial the correction, and include the date and time. This method maintains the integrity of the documentation while clearly indicating that an error was made and corrected.

B. Use a permanent marker to draw a line through the error and write "mistaken entry": Using a permanent marker is not appropriate because it can make the chart difficult to read and may obscure the original information. Additionally, writing "mistaken entry" does not provide sufficient clarification regarding the nature of the error or the correction made.

C. Cover the mistake with correction fluid and skip a line: Using correction fluid to cover the mistake is not recommended because it can make the chart appear altered or tampered with. Skipping a line does not adequately address the error and correction, and it may lead to confusion when reviewing the documentation.

D. Erase the error and write the correct information: Erasures are not recommended in documentation as they can be perceived as altering or tampering with the chart. Additionally, erasing information may not completely remove it from the chart, and it may still be legible under certain lighting conditions or with the use of special equipment.

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Correct Answer is ["A","E"]

Explanation

When administering an enema to an adult patient with constipation, the nurse must insert the tubing into the patient's rectum to deliver the enema solution effectively. However, it's crucial to avoid inserting the tubing too far to prevent injury or discomfort to the patient. The recommended insertion distance varies depending on the individual patient's anatomy and the type of enema being administered.

A. 4 in. (10.2 cm):

Inserting the enema tubing approximately 4 inches (10.2 cm) into the patient's rectum is considered a safe and effective distance for most adult patients. This depth allows the enema solution to reach the sigmoid colon, facilitating the evacuation of stool and relieving constipation without risking insertion too deeply into the rectum.

B. 5 in (12.7 cm): Inserting the tubing 5 inches into the rectum is generally deeper than necessary and may increase the risk of injury or discomfort. This distance is not typically recommended for safe and effective administration of an enema.

C. 6 in. (15.25 cm): Inserting the tubing 6 inches into the rectum is deeper than necessary and may increase the risk of injury or discomfort. This distance is generally not recommended for safe and effective administration of an enema.

D. 2 in. (5.1 cm): Inserting the tubing 2 inches into the rectum is not considered a safe and effective distance for many adult patients. This distance does not allow for the effective delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

E. 3 in. (7.6 cm): Inserting the tubing 3 inches into the rectum is also considered a safe and effective distance for many adult patients. This distance allows for the delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

A. Administering diuretics as ordered B. Providing good skin and mouth care C. Monitoring intake and output D. Obtaining daily weights

Correct Answer is ["B","C","D"]

Explanation

A. Administering diuretics as ordered: This option is not appropriate for dehydration management. Diuretics are medications that increase urine output and are typically used to treat fluid overload rather than dehydration. Administering diuretics to a dehydrated client could exacerbate fluid loss and worsen the condition.

B. Providing good skin and mouth care: This is a suitable intervention for managing dehydration. Dehydration can lead to dry skin and mucous membranes. Providing good skin care, including moisturizing, can help prevent skin breakdown. Additionally, ensuring adequate oral hygiene and providing moist mouth swabs can alleviate discomfort associated with dry mouth.

C. Monitoring intake and output: This is an essential nursing intervention for managing dehydration. Monitoring the client's fluid intake and output allows the nurse to assess the balance between fluid intake and loss. Decreased urine output is a common sign of dehydration, while monitoring intake helps ensure the client is receiving adequate fluids.

D. Obtaining daily weights: This is an appropriate nursing intervention for managing dehydration. Daily weights can help assess changes in fluid balance. A sudden increase in weight may indicate fluid retention, while a decrease may indicate ongoing fluid loss, both of which are important to monitor in dehydration.

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The nurse makes an error while documenting in the client's chart. The nurse should:

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Naxlex Comprehensive Predictor Exams

The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

Correct Answer is ["A","E"]

Explanation

The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

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