The practical nurse (PN) is charting vital signs on a hand-writen flow sheet and realizes that an error has been made. What should the PN do to rectify this error?
Obliterate the entry and insert the correct information
Draw one line through the entry and insert the correct information
Chart the correct information in the next column.
Notify the charge nurse that the entry needs to be revised
The Correct Answer is B
This is the correct way to correct an error on a hand-writen chart, according to the legal and ethical principles of documentation. The PN should also initial and date the correction.
Obliterating the entry or charting in the next column can create confusion and suspicion of tampering with the records. Notifying the charge nurse is not necessary unless the error has serious implications for the client's care or safety
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Ineffective airway clearance.
Choice A rationale:
Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
Correct Answer is C
Explanation
Choice A rationale: Enrollment in a remedial education class is unnecessary because the UAP is currently demonstrating the correct, evidence-based technique for providing oral care to an unconscious client to prevent aspiration.
Choice B rationale: While positive reinforcement is beneficial, the primary focus should be on the clinical safety of the procedure. Encouraging family participation is secondary to ensuring the UAP maintains proper safety protocols.
Choice C rationale: The side-lying position, combined with a towel and basin under the chin, allows secretions to drain out of the mouth by gravity. This is the safest position to prevent aspiration.
Choice D rationale: Placing an unconscious client in Fowler's position increases the risk of the tongue falling back and secretions being aspirated into the lungs. The flat, side-lying position is much safer.
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