Which of these statements about documentation are true?
(Select all that apply.).
Documentation should be done as soon as possible after an event has occurred.
Documentation should include objective data, subjective data, and nursing interventions.
Documentation should use abbreviations, symbols, and acronyms that are approved by the facility.
Documentation should include opinions, judgments, and assumptions about the client’s condition.
Documentation should reflect the nursing process and the standards of care.
Correct Answer : A,B,C
Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care. Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs. Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.
Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate. Documentation should be factual, accurate, and objective.
Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement. Documentation should also reflect the patient’s perspective, preferences, and goals. Documentation should be patient-centered, holistic, and individualized.
Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.
However, some general ranges are:.
• Temperature: 36.5°C to 37.5°C.
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: 120/80 mmHg or lower.
• Oxygen saturation: 95% or higher.
Sources:.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
The nurse should include factual information about what happened and notify the risk management department.These actions are part of the steps of reporting medication errorsand the good practice guide on recording, coding, reporting and assessment of medication errors.
Choice B is wrong because the nurse should not state opinions about who was responsible for the error.
This could be seen as biased, unprofessional or accusatory.
The nurse should focus on the facts and the causes of the error, not on blaming individuals.
Choice C is wrong because the nurse should not file the report in the client’s medical record.
This could violate the client’s privacy and confidentiality.
The report should be filed in a separate system that is accessible only to authorized personnel.
Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.
This could be premature, unrealistic or inappropriate.
The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.
Correct Answer is B
Explanation
“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.
• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.
• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.
• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.
• Documenting in a timely manner to minimize errors and omissions.
The other choices are wrong because:.
• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client.It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.
• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation.It can also lead to legal action if the documented events do not match the actual events.
• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.
Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.
They may vary according to different sources and standards.
Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.