Question

A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first?

a) Ensure that the staff nurse changes the dressing.
b) Notify the nurse manager.
c) Complete an incident report.
d) Gather more information about the staff nurse's actions.

Answer 1

In Nursing, when incorrect documentation is noted, the first step is to gather more information about the staff nurse's actions before deciding the course of further action, such as performing the procedure or reporting the incident.

Step-by-step explanation:

The subject of this question is Nursing, specifically related to ethical conduct and appropriate steps of action within a healthcare setting. When a charge nurse observes a staff nurse documenting a procedure that was not performed, which is a serious misdemeanor in the clinical setting, the first step they should take is to gather more information. This may involve directly questioning the staff nurse and reviewing the situation to obtain a clear picture of what occurred. Only with the correct information can the charge nurse make an informed decision about subsequent actions, such as ensuring the dressing change is performed, notifying the nurse manager, and completing an incident report.