Who should document care in the patient record?
The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.
The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.
All staff members should document all of the care that they have provided.
All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.
The Correct Answer is C
A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.
B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.
C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.
D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.
B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.
C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.
D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.
Correct Answer is B
Explanation
A. To clarify nursing principles: Nursing orders are action-oriented and not just meant to clarify theoretical principles.
B. To resolve the patient’s problems: Nursing orders focus on patient care interventions that directly address identified problems in the nursing diagnosis.
C. To support physician’s orders: Nursing orders complement medical care but are independent nursing actions, not just support for physician directives.
D. To provide broad, general statements: Nursing orders should be specific, measurable, and actionable, not broad statements.
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