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A manager who is reviewing the nurses' notes in a
patient's medical record finds the following entry, "Patient
is difficult to care for, refuses suggestion for improving
appetite." Which of the following directions does the
manager give to the staff nurse who entered the note?
A) Avoid rushing when charting an entry.
B) Use correction fluid to remove the entry.
C) Draw a single line through the statement and initial it.
,D) Enter only objective and factual information about the
patient. - ANSWER-D) Enter only objective and factual
information about the patient.
Nurses should enter only objective and factual information
about patients. Opinions have no place in the medical
record. Because the information has already been entered
and is not incorrect, it should be left on the record. Never
use correction fluid in a written medical record.
What would the nurse do if he or she were not able to
insert a nasogastric tube in either of a patient's nares?
Ask another nurse to attempt the insertion.
Document the attempts in the patient's medical record.
,Notify the physician that the attempts were unsuccessful.
Allow the patient to rest for 30 minutes before resuming
the process. - ANSWER-Notify the physician that the
attempts were unsuccessful.
The nurse would notify the physician because he or she
will need to attempt to insert the tube or determine another
treatment option.
Attempting to insert a tube again may harm the patient.
Although documentation is necessary, it does not address
the patient's need for a nasogastric tube.
Delaying an attempt at inserting the nasogastric tube
makes success no more likely and risks harming the
patient.
, What would the nurse do if he or she encountered
resistance when inserting a nasogastric tube?
Ask the patient to cough.
Withdraw the tube to the nasopharynx.
Encourage the patient to swallow.
Instruct the patient to hyperextend the neck. - ANSWER-
Withdraw the tube to the nasopharynx.
If the patient starts to cough, experiences a drop in oxygen
saturation, or shows other signs of respiratory distress,
withdraw the tube into the posterior nasopharynx until
normal breathing resumes. Do not force the tube or push it
against resistance.