A nurse is documenting a patient’s vital signs in the electronic health record (EHR). The patient’s temperature is 100.8°F orally, heart rate is 88 bpm, respiratory rate is 18 breaths per minute, and blood pressure is 120/80 mmHg. The nurse notices that the temperature value entered in the EHR is 108.0°F. What action should the nurse take?
A) Change the temperature value to 98.0°F to reflect a normal reading. B) Leave the incorrect value as is and document the correct value in the progress notes. C) Delete the temperature value and leave it undocumented. D) Correct the temperature value to 100.8°F and document a late entry with an explanation. E) Inform the charge nurse but take no further action.
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Rationale: This question evaluates the nurse’s understanding of documentation accuracy and error correction. It assesses the nurse’s knowledge of handling incorrect entries in the EHR, emphasizing the importance of correcting errors promptly and transparently to maintain accurate patient records. Correct Answer: D) Correct the temperature value to 100.8°F and document a late entry with an explanation.
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A nurse is documenting the care provided to a patient admitted with pneumonia. While recording the administration of prescribed antibiotics, the nurse notices the patient’s allergy to penicillin was not documented upon admission. What should the nurse do first?
A) Discontinue the antibiotic and notify the healthcare provider. B) Document the allergy immediately in the patient’s chart. C) Wait until the end of the shift to inform the charge nurse. D) Notify the pharmacy about the allergy. E) Continue administering the antibiotic but monitor the patient closely.
Rationale: This question tests the nurse’s prioritization skills and understanding of patient safety related to documentation. Recognizing an undocumented allergy during medication administration requires immediate action to prevent harm, emphasizing the need to discontinue the medication and inform the healthcare provider promptly. Correct Answer: A) Discontinue the antibiotic and notify the healthcare provider.
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NCLEX Practice Questions: Understanding Nursing Documentation Causes and Symptoms
During a routine assessment, a nurse notices a discrepancy between the patient’s stated pain level and the pain score documented by a colleague in the electronic health record. The patient reports severe pain (8/10), but the chart notes mild pain (2/10). What should the nurse do?
A) Document the patient’s reported pain level without any changes. B) Update the documentation to match the patient’s reported pain level. C) Notify the patient’s family about the discrepancy. D) Discuss the inconsistency with the colleague who documented the pain score. E) Ignore the difference in documentation as pain perception can vary.
Rationale: This question assesses the nurse’s understanding of accurate documentation based on patient-reported information. Ensuring that the documentation reflects the patient’s actual condition is crucial for appropriate care and treatment, highlighting the importance of updating records to align with the patient’s current status. Correct Answer: B) Update the documentation to match the patient’s reported pain level.
Understanding Nursing Documentation: Causes and Symptoms
While documenting a patient’s vital signs, a nurse accidentally enters the blood pressure reading of 140/90 mmHg in the wrong patient’s electronic health record. What action should the nurse take immediately?
A) Notify the charge nurse about the error. B) Leave the incorrect entry and document the correct reading in the progress notes. C) Delete the entry from the incorrect record. D) Correct the entry in the wrong record and document a late entry in the correct record. E) Wait until the next vital sign check to input the correct reading.
Rationale: This question evaluates the nurse’s response to documentation errors made in the electronic health record. Immediate notification of errors to supervisory staff helps initiate the proper corrective actions and prevents potential adverse consequences arising from incorrect documentation. Correct Answer: A) Notify the charge nurse about the error.
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Understanding Nursing Documentation: NCLEX Priority Questions
During shift handoff, the outgoing nurse informs the incoming nurse about a wound dressing change performed on a patient’s leg ulcer. The incoming nurse forgets to document this information. What action should the incoming nurse take?
A) Document the wound dressing change in the patient’s chart at the end of the shift. B) Ask the outgoing nurse to document the wound dressing change. C) Leave the documentation blank as the incoming nurse forgot to document. D) Document the wound dressing change at the beginning of the next shift. E) Document the missed wound dressing change immediately and include a late entry notation.
Rationale: This question assesses the nurse’s understanding of documentation responsibilities and actions following a missed documentation opportunity. Documenting the missed task immediately with a late entry notation maintains the accuracy and completeness of the patient’s record while acknowledging the timing discrepancy. Correct Answer: E) Document the missed wound dressing change immediately and include a late entry notation.
NCLEX Questions: Focus on Medications for Nursing Documentation
A nurse is documenting a wound assessment for a patient with a stage II pressure ulcer on the sacrum. The nurse notes the wound’s size, exudate amount, and presence of necrotic tissue. Which documentation format would be most appropriate for this wound assessment?
A) SOAP (Subjective, Objective, Assessment, Plan) B) PIE (Problem, Intervention, Evaluation) C) Focus Charting D) Narrative Charting E) Flowcharting
Rationale: This question assesses the nurse’s comprehension of different documentation formats. Understanding which format best suits specific assessments, in this case, wound assessment details, demonstrates the nurse’s proficiency in organizing and conveying patient information effectively. Correct Answer: A) SOAP (Subjective, Objective, Assessment, Plan)
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NCLEX Focus Exploring Nursing Documentation: Causes and Diagnosis
A nurse is documenting the administration of medication to a patient with hypertension. The nurse administered the medication at 10:30 AM but accidentally documented it as 11:30 AM. What should the nurse do to correct this documentation error?
A) Leave the documentation as is since it was only a one-hour difference. B) Draw a single line through the incorrect entry, write the correct time, and initial it. C) Erase the incorrect documentation and rewrite the correct time without any additional notation. D) Request another nurse to document the correct time. E) Inform the physician about the error and follow their instructions.
Rationale: This question evaluates the nurse’s understanding of error correction in medication documentation. It focuses on the proper procedure for correcting a documentation error related to medication administration, emphasizing the importance of maintaining an accurate record while adhering to established protocols. Correct Answer: B) Draw a single line through the incorrect entry, write the correct time, and initial it.
NCLEX Questions Critical Thinking: Nursing Documentation Symptoms
A nurse is documenting the care provided to a patient recovering from surgery. While recording the administration of pain medication, the nurse notices that the medication was given 30 minutes later than the prescribed time. What should the nurse do first?
A) Document the administration time as per the prescribed schedule. B) Notify the charge nurse about the delayed medication administration. C) Document the actual administration time and reason for the delay. D) Don’t document the delay as it was within a reasonable timeframe. E) Omit documentation about the delayed administration.
Rationale: This question evaluates the nurse’s response to delayed medication administration. It assesses the understanding of accurate documentation practices by emphasizing the importance of documenting deviations from the prescribed schedule to maintain transparency and provide a clear record of patient care. Correct Answer: C) Document the actual administration time and reason for the delay.
NCLEX Review: Nursing Documentation Treatments
During a shift change, a nurse receives handoff information about a patient’s recent fall in the bathroom. However, the nurse forgets to document this incident in the patient’s chart. What action should the nurse take?
A) Document the fall incident in the patient’s chart at the end of the shift. B) Ask another nurse to document the fall incident. C) Inform the charge nurse about forgetting to document the fall. D) Leave the documentation blank since it was missed during handoff. E) Document the missed fall incident immediately and include a late entry notation.
Rationale: This question assesses the nurse’s understanding of documentation responsibilities after a missed entry opportunity. It emphasizes the importance of immediate documentation with a late entry notation to ensure completeness and accuracy in the patient’s record, even after the oversight during handoff. Correct Answer: E) Document the missed fall incident immediately and include a late entry notation.
While documenting a patient’s intake and output (I&O) for the shift, the nurse notices a discrepancy between the recorded intake and output values. The intake appears higher than the output recorded. What should the nurse do?
A) Document the I&O values as they are without changes. B) Update the documentation to reflect the accurate I&O values. C) Inform the patient about the discrepancy in their intake and output. D) Discuss the discrepancy with the nursing assistant responsible for I&O recording. E) Ignore the difference in documentation since it might be insignificant.
Rationale: This question assesses the nurse’s response to a discrepancy in recorded intake and output values. It highlights the importance of ensuring accurate documentation that aligns with the patient’s actual intake and output, emphasizing the need to update the records to reflect the true values for proper patient care and monitoring. Correct Answer: B) Update the documentation to reflect the accurate I&O values.