Author Question: The registered nurse (RN) has made an error in documenting an assessment finding on a client in the ... (Read 78 times)

lunatika · **on:** Jul 22, 2018

The registered nurse (RN) has made an error in documenting an assessment finding on a client in the client's record and obtains the record to correct the error. The RN corrects the error by:

1. Documenting a late entry into the client's record
2. Trying to erase the error to make space for writing in the correct data
3. Using white correction fluid to delete the error and writing in the correct data
4. Drawing one line through the error, initialing and dating the line, and then providing the correct information

Question 2

The registered nurse (RN) is caring for a client with severe cardiac disease. While caring for the client, the client states, If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me.

The most appropriate nursing action is to: 1. Tell the client that the family must agree with the request.
2. Plan a client conference with the nursing staff to share the client's request.
3. Tell the client that it is necessary to notify the physician of the client's request.
4. Tell the client that this procedure cannot legally be refused by a client if the phy-sician believes that it is necessary to save the client's life.

Danny Ewald · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4

Rationale: If the nurse makes an error in documenting in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, ini-tialing and dating the line, and then providing the correct information. Erasing data from the cli-ent's record and using white correction fluid are prohibited. A late entry is used to document ad-ditional information not remembered at the initial time of documentation. Procedures for cor-recting an error via the use of electronic documentation may be different and the nurse should follow agency guidelines.

Answer to Question 2

3

Rationale: External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician, because a written Do Not Resuscitate (DNR) prescription from the physician must be present on the client's record. The DNR pre-scription must be reviewed or renewed on a regular basis per agency policy. Tell the client that the family must agree with the request and tell the client that this procedure cannot legally be refused by a client if the physician believes that it is necessary to save the client's life are inac-curate. Plan a client conference with the nursing staff to share the client's request may be ap-propriate but only after the physician is contacted and notified of the client's request.