Question

The nurse, after administering antibiotics, is updating a patient's chart in the emergency room. What elements of the report does the nurse accurately document in order to limit nursing liability in case of a legal claim? Select all that apply.

a) Current medications given

b) Discontinued medications

c) Drug allergies

d) Name of drug manufacturer

e) Size, shape, and color of the pills

Answer 1

To limit nursing liability in case of a legal claim, the nurse should accurately document current medications given, discontinued medications, drug allergies, and the name of the drug manufacturer in the patient's chart.

Step-by-step explanation:

In order to limit nursing liability in case of a legal claim, the nurse should accurately document the following elements in the patient's chart:

• Current medications given: This includes any antibiotics or other medications administered to the patient.
• Discontinued medications: Any medications that were stopped or changed should be documented.
• Drug allergies: Any known drug allergies or adverse reactions experienced by the patient should be recorded.
• Name of drug manufacturer: This information helps in case of any issues or recalls related to the medication.

Size, shape, and color of the pills do not typically need to be documented for legal liability purposes, but they may be helpful for ensuring accurate medication administration.