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Medical Language for Modern Health Care4th EditionDavid M Allan, Rachel Basco 2,732 solutions 3. A charge nurse is reviewing documentation witha group of newly licensed nurses. Which of thefollowing legal guidelines should be followed whendocumenting in a client’s record? (Select all that apply.)A. Cover errors with correction fluid, andwrite in the correct information.B. Put the date and time on all entries.C. Document objective data, leaving out opinions.D. Use as many abbreviations as possible.E. Wait until the end of the shift to document. 4. A nurse is discussing occurrences that requirecompletion of an incident report with a newly licensednurse. Which of the following should the nurseinclude in the teaching? (Select all that apply). 5. A nurse is receiving a provider’s prescription bytelephone for morphine for a client who is reportingmoderate to severe pain. Which of the followingnursing actions are appropriate? (Select all that apply.) E. Tell the charge nurse that the provider hasprescribed morphine by telephoneExamples of tasks nurses maydelegate to PNs and APs(provided the facility’s policy andstate’s practice guidelines permit)TO PNS● Monitoring findings(as input to the RN’songoing assessment)● Reinforcing client teachingfrom a standard care plan● Performingtracheostomy care● Suctioning● Checking NGtube patency● Administeringenteral feedings● Inserting a urinarycatheter● Administering medication(excluding IV medicationin some states)TO APS● Activities of dailyliving (ADLs)Bathing◯Grooming◯Dressing◯Toileting◯Ambulating◯Feeding (without◯swallowing precautions)Positioning◯● Routine tasksBed making◯Specimen collection◯Intake and output◯Vital signs◯2 The five rights of delegationRight task Right circumstanceRight personRight direction and communicationRight supervision and evaluation\A nurse on a medical-surgical unit has receivedchange-of-shift report and will care for fourclients. Which of the following tasks should the Which of the following information should the nurse include as a benefit of electronic documentation?Which of the following information should the nurse include as a benefit of electronic documentation? The system alerts providers of possible actions that could cause client harm.
What is the responsibility of the nurse as a witness to informed consent quizlet?The nurse's role in the informed consent process is to witness the client's signature on the informed consent form and to ensure that the provider has obtained the informed consent responsibly.
What is contemporaneous nursing documentation?Document contemporaneously
Nurses and midwives should record entries in the patient's notes as soon as possible after the events to which reference is being made have occurred, with the date and time for each entry recorded. All entries should also include the author's signature, printed name and designation.
Who advocated for nationwide use of EHR's?Bush advocated for a nationwide EHR in his State of the Union Address to reduce “medical mistakes, reduce costs and improve care.” 1 Since then numerous other terms that sound similar to EHR have been used by the media and in the literature, such as computer- based patient record (CPR), electronic medical record (EMR) ...
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