Fundamentals of Nursing Q 398
As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The RN has correctly chartered the dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first?
A. Make a note in the nurse’s file and continue to observe clinical performance.
B. Refer the new nurse to the in-service education department.
C. Quiz the nurse about knowledge of pain management.
D. Give praise for the correct dose and time and discuss the deficits in charting.
Correct Answer: D. Give praise for the correct dose and time and discuss the deficits in charting.
In supervising the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal.
Option A: Making a note and watching do not help the nurse to correct the immediate problem. Nursing activity that has been completed or that will take place should be properly documented. Accurate documentation and reports play a pivotal role in health services. This documentation is necessary to identify nursing interventions that have been provided to patients and to show patient progress during hospitalization.
Option B: In-service might be considered if the problem persists. Nursing documentation also serves as an effective tool of inter-professional communication between nurses and other health professionals for delivering ongoing nursing care, evaluating patient progress and outcomes, and providing constant patient protection. High-quality nursing documentation may improve the effectiveness of communication between health professionals in first- and higher-level healthcare facilities.
Option C: Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. It is also an indicator of nurse performance and the nursing service quality in a hospital. Documentation provides details of patient condition, nursing interventions that have been provided, and patient response to the intervention(s).