Answer to Question 1
ANS: C
Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged.
Answer to Question 2
ANS: A
An admission summary includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs. The discharge summary addresses the patient's hospital course and plans for follow-up, and it documents the patient's status at discharge. It includes information on medication and treatment, discharge placement, patient education, follow-up appointments, and referrals. Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station.
A nurse adjusts the rate of a client’s IV.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
Suctioning a tracheostomy to remove secretions.
Sources of diagnostic error
Ergonomically correct desk, chair, and keyboard.
Nurse administering enteral nutrition through a feeding tube.