Portage Learning; MED Nursing Fundamentals Week 3 Exam and Summary/Definition in this one Document (Latest)

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Portage Learning; MED Nursing Fundamentals Week 3 Exam and Summary/Definition in this one Document (Latest) A manager is reviewing the nursing documentation entered by a staff nurse in a patient's ... electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? 1. "Avoid rushing when documenting an entry in the medical record." 2. "Use correction fluid to remove the entry." 3. "Draw a single line through the statement and initial it." 4. Enter only objective and factual information about a patient in the medical record. ---4. Enter only objective and factual information about a patient in the medical record. A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: 1. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. 2. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. 3. Gives a newly ordered medication before entering the order in the patient's medical record. 4. Asks the preceptor to listen in on the phone conversation. ---3. Gives a newly ordered medication before entering the order in the patient's medical record. [Show More]

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