The Nurse Makes a Late Entry in a Client's Record

question 25

Multiple Choice

The nurse makes a late entry in a client's record.Which of the following is the best example of how to document this type of situation?

• A) "2:45 PM-ASA gr X given for temperature of 38.1° C."
• B) "8:30 AM-Client received Percodan (1 tablet)PO an hour before going to radiology."
• C) "12:15 PM-I gave the client morphine 10 mg IM at 11:10 AM but did not document it then."
• D) "8:30 PM-Abdominal dressing change at 7:30 PM.No s/s of infection,and wound edges approximating well."

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Definitions:

Widely Understood Rules

Norms, guidelines, or principles that are generally accepted and recognized by a large group of people.

Situated Identity

A conception held by a person in a situation that indicates who he or she is in relation to the other people involved in that situation.

Front Region

A term in sociolinguistics and social psychology referring to the setting or stage where individuals perform certain roles under social observation.

Ingratiation

The deliberate use of deception to increase a target person's liking for us in hopes of gaining tangible benefits that the target person controls. Techniques such as flattery, expressing agreement with the target person's attitudes, and exaggerating one's own admirable qualities may be used.