The nurse is documenting care provided to a client. Which action ...

[NguyenJ]

The nurse is documenting care provided to a client. Which action should the nurse take to demonstrate the avoidance of potentially confusing abbreviations when documenting?
 
  1. Documenting vital signs as TPR.
  2. Charting that the drsg was dry and intact.
  3. Transcribing a verbal order as Carbamazepine 12 mcg/ml IV push daily.
  4. Documenting Client consistently requesting IM MS for pain well before prescribed time.
  5. Charting, Client to be ambulated q.i.d.

Question 2

The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system?
 
  1. The system is relatively inexpensive to maintain.
  2. Bedside terminals eliminate worksheets and note taking.
  3. The system links to various sources of client information.
  4. The system better protects client privacy.
  5. Information is legible.
  6. Results, requests, and client information can be sent and received quickly.

[ASDFGJLO]

Answer to Question 1

Correct Answer: 1, 2, 5
Rationale 1: This is a commonly used and accepted abbreviation for temperature, pulse, and respirations (vital signs).
Rationale 2: This is a commonly used and accepted abbreviation for a treatment dressing.
Rationale 3: Mcg (micrograms) is not an accepted abbreviation, as it can be confused with mg (milligrams), resulting in a one thousandfold overdose.
Rationale 4: MS is not an accepted abbreviation for morphine sulfate, as it can be confused with magnesium sulfate, resulting in a drug error.
Rationale 5: This is a commonly used and accepted abbreviation for four times a day.

Answer to Question 2

Correct Answer: 2, 3, 5, 6
Rationale 1: This system is not inexpensive to maintain.
Rationale 2: This is considered a positive aspect of this type of charting.
Rationale 3: This is considered a positive aspect of this type of charting.
Rationale 4: The effectiveness of this system to protect a client's privacy is dependent upon the personnel using it.
Rationale 5: This is considered a positive aspect of this type of charting.
Rationale 6: This is considered a positive aspect of this type of charting.