Author Question: The nurse who forgets to document an element of clinical significance and recalls it later should ... (Read 80 times)

tiara099 · **on:** Jul 22, 2018

The nurse who forgets to document an element of clinical significance and recalls it later should

a. not add this information to the chart since it will be out of sequence
b. add this information to the original entry and initial it
c. rewrite the original entry
d. include this information, dating and signing the additional material

Question 2

A client recovering from surgery begins to have an increase in body temperature and carbon dioxide level. Which of the following should the nurse do first?

1. Provide dantrolene.
2. Contact the anesthesiologist.
3. Assess for patent intravenous line.
4. Provide 100 oxygen with a nonrebreather mask.

LP · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
When the nurse forgets to document significant data, it is appropriate and advisable to include these data at a later date. Common practice is to enter the date and time and label Late entry to indicate that it is out of sequence. Then record the date and time it should have been charted in the body of the entry.

Answer to Question 2

4. Provide 100 oxygen with a nonrebreather mask.

Rationale:
An increase in body temperature and carbon dioxide level are indications that the client is developing malignant hyperthermia. The first thing the nurse should do is apply 100 oxygen with a nonrebreather mask. The nurse should then ensure good intravenous access and contact the anesthesiologist. The anesthesiologist will order dantrolene for administration.