Answer to Question 1
D
D. Information within a recorded entry must be complete, containing appropriate and essential information. This notation provides the time and action taken by the nurse, including the reason for doing so.
A. This entry does not indicate what the vital signs were.
B. This entry does not provide a specific amount the client drank. Stating adequate is subjective, not objective.
C. This notation does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the client's pain was in the lower left or lower right quadrant, or both.
Answer to Question 2
C
In older children, the suction catheter is inserted about 16 to 20 cm or 6 to 8 inches. The catheter is always inserted during inspiration. The catheter should be lubricated with water-soluble lubricant to avoid lipid aspiration pneumonia from a petroleum-based gel. The procedure requires sterile gloves, at least on one hand. The trachea should be suctioned before the pharynx because the mouth and the pharynx contain more bacteria than the trachea.
The nurse conducts the health history as the first step in the nursing assessment
The nurse applies a pulse oximeter sensor on the client’s finger.
Client receiving hemodialysis.
Building competency in patient centered care
Nurse using a stethoscope
Handbook of Informatics for Nurses and Health Care Professionals, 4/E