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A nurse enters a notation in a patient's medical record but then discovers that the notation was made in the wrong chart. The nurse correctly:

A.

follows agency policy for correcting the error.

B.

whites out the wrong entry and writes the note in the chart of the correct patient.

C.

removes the page on which the error is located and documents the other correct notes.

D.

blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.

Answer and Explanation

The Correct Answer is A

A. Follows agency policy for correcting the error.
Following agency policy is the best approach, as it ensures compliance with legal and procedural standards for correcting documentation errors.

 

B. Whites out the wrong entry and writes the note in the chart of the correct patient. Whiting out errors is not permissible, as it can appear as an attempt to alter records and compromises the integrity of documentation.

 

C. Removes the page on which the error is located and documents the other correct notes. Removing pages from a medical record is improper and could be considered tampering with documentation.

 

D. Blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.
Blacking out notes is not allowed, as it destroys information that should remain legible, even if it was written in error.


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Correct Answer is D

Explanation

A. "I don't feel like walking today either."
This response shifts the focus from the patient to the nurse and does not encourage further discussion about the patient's reluctance or explore the reasons behind it.

B. "You have to walk today."
This statement sounds forceful and dismissive, and may make the patient feel pressured rather than supported. It does not invite dialogue or provide understanding.

C. "Why don't you want to walk today?"
This question can sound judgmental and may put the patient on the defensive. A more neutral response would help the nurse understand the patient's reluctance without pressure.

D. "You don't want to walk today?"
This response reflects the patient's own words back, validating their feelings and opening up the opportunity for the patient to explain their reasons. It is empathetic and nonjudgmental, which encourages therapeutic communication.

Correct Answer is C

Explanation

A. Test the patient's reading comprehension before using visual handouts.
Testing reading comprehension can be helpful but is not sufficient on its own to assess the patient’s overall learning preferences or needs.

B. Use a hands-on approach, because it works best for most people.
While hands-on learning is effective, assuming it works best for everyone may overlook individual learning preferences.

C. Ask the patient whether he learns best visually, aurally, or kinesthetically. Asking the patient’s learning preferences enables the nurse to tailor education to the patient's strengths.

D. Use a combination of the three modes of learning to enhance learning. Combining all modes without considering the patient's preferences may not be as effective as directly addressing the patient's specific learning style.

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