Legally speaking, how would the nurse ensure that care was not ...

[rosent76]

Legally speaking, how would the nurse ensure that care was not negligent?
 
  A) Verbally reporting assessments to the client's physician
  B) Keeping private notes about the care given to each assigned client
  C) Documenting the nursing actions in the client's record
  D) Tape recording complete information for each oncoming shift

Question 2

Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using?
 
  A) Assessing
  B) Planning
  C) Implementing
  D) Evaluating

[dudman123]

Answer to Question 1

Ans: C
Legally speaking, a nursing action not documented in the client's record is a nursing action not performed. Unless the record contains written (not verbal, tape-recorded, or in private notes) documentation of care provided, the court would have no reason to accept a nurse's claim that the care was given.

Answer to Question 2

Ans: C
During the implementing step of the nursing process, the nurse carries out interventions that were developed during the planning step.