How does the RN document the incident when an atraumatic needle is missing after a knee arthroscopy, and an X-ray is negative?

A. Document that the count was incorrect or unreconciled and describe the steps that were taken to rectify the count.
B. Document that the count was correct because the X-ray was negative.
C. Notify the supervisor and document what he or she instructs according to policy.
D. Inform the patient that a needle may have been left in the wound.

The RN should document that the count was incorrect, and describe all steps taken to find the missing needle, including the negative X-ray results. The surgeon’s actions and any instructions from the supervisor should also be included in the documentation.

Explanation:

In the situation where an atraumatic needle is missing following a knee arthroscopy, the RN (Registered Nurse) should document that the count was incorrect or unreconciled and describe all the steps that were taken to rectify the count. This includes recording the performance of an X-ray scan and communicating the results. In this specific case, since the X-ray results were negative, this information must be included in the documentation. The actions of the surgeon, such as closing the wound, should also be documented. Additionally, the RN must notify the supervisor and document any instructions provided, following the hospital's policy. The patient should never be unnecessarily alarmed by information such as the possibility of a needle being left in the wound, especially when the X-ray result is negative and the surgeon has closed the wound.

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