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After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Request removal initiated by the Health Information Manager.

Create an electronic correction after 1400 notes are officially unlocked.

Enter the occurrence after the 1400 notes and identify as “late entry.”.

Make an electronic addendum following the 1400 documentation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation. This approach does not address the need to document the 0900 occurrence.

Choice B rationale

Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

Choice C rationale

Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an option, but it may not provide sufficient clarity regarding the timing of the documentation. Using a “late entry” label could potentially lead to confusion or misinterpretation.

Choice D rationale

Making an electronic addendum following the 1400 documentation is the best approach. An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It ensures accuracy and transparency in the medical record.

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A. Determine client’s subjective measure of pain using a numerical pain scale. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Assist the client to ambulate as much as possible during waking hours. D. Provide comfort measures such as topical warm application and tactile massage. E. Encourage increased fluid intake and measure urinary output every 8 hours.

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

Explanation

Choice A rationale

Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.

Choice B rationale

Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.

Choice C rationale

Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.

Choice D rationale

Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.

Choice E rationale

Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.

A. Complete an adverse occurrence/incident report. B. Ensure that the restraints are not too tight. C. Initiate the facility’s restraint flow sheet. D. Demonstrate proper securing of the restraints.

Correct Answer is D

Explanation

Choice A rationale

Completing an adverse occurrence/incident report is important if an incident occurs, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice B rationale

Ensuring that the restraints are not too tight is important for the client’s safety and comfort, but it does not address the improper securing of the restraints to the bedside rails. The restraints should be secured to a movable part of the bed frame, not the rails.

Choice C rationale

Initiating the facility’s restraint flow sheet is necessary for documentation, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice D rationale

Demonstrating proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.

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After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

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

Explanation

Correct Answer is D

Explanation

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Take full exam for free After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

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The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

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

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is D

Explanation

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After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?