The charge nurse is evaluating the documentation of the new staff ...

[james9437]

The charge nurse is evaluating the documentation of the new staff nurse. Based on which of the following does the charge nurse note, on review of the charting, that appropriate documentation is evident?
 
  a. The new staff nurse used a pencil to make the entries.
  b. The new staff nurse used correction fluid to correct written errors.
  c. The new staff nurse identified an error made by the attending physician.
  d. The new staff nurse has dated and signed all of the entries he or she made in the record.

Question 2

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action?
 
  a. Preparing the patient for a second tap water enema
  b. Donning gloves for digital removal of the stool
  c. Positioning the patient on the left side
  d. Inserting a rectal tube

[JaynaD87]

Answer to Question 1

D
Each entry should begin with the time of entry and end with the signature and title of the nurse who recorded the entry.
All entries should be recorded legibly and in black ink because pencil can be erased.
The nurse should never erase entries or use correction fluid, and never use a pencil. The use of correction fluid could render the charting illegible, and it may appear as if the nurse were at-tempting to hide something or deface the record.
If the physician made an error, the nurse should not document it in the client's chart; the error should be documented in an incident report.

Answer to Question 2

B
When enemas are not successful, digital removal of the stool may be necessary occasionally to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence but would not be applicable or effective for this patient.