Author Question: Which of the following is evaluated as a legally appropriate notation? a. Dr. Green made an error ... (Read 52 times)

kfurse · **on:** Jul 22, 2018

Which of the following is evaluated as a legally appropriate notation?

a. Dr. Green made an error in the amount of medication to administer.
b. Client verbalized sharp, stabbing pain along the left side of chest.
c. Nurse Williams spoke with the client about the surgery.
d. Client upset about the physiotherapy.

Question 2

A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important?

a. Ensuring that the patient does not eat or drink 2 hours before the examination
b. Removing all of the patient's metallic jewelry
c. Administering a colon cleansing product 12 hours before the examination
d. Obtaining an order for a pain medication before the test is performed

emilymalinowski12 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Entries should be concise, factual, and accurate. The entry Client verbalized sharp, stabbing pain along the left side of chest is an example of an objective description of a client's behaviour.
The nurse should not document physician made error. Instead, the nurse could chart, Dr. Green was called to clarify order for medication administration.
The nurse should chart only for himself or herself. In this case, Nurse Williams should write the charting entry.
Only objective descriptions of the client's behaviour should be recorded. For example, Client states, I don't want physiotherapy I want to go home'

Answer to Question 2

B
No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.