Author Question: The nurse makes a late entry in a client's record. Which of the following is the best example of how ... (Read 45 times)

Medesa · **on:** Jul 22, 2018

The nurse makes a late entry in a client's record. Which of the following is the best example of how to document this type of situation?

a. 2030 hrs: Client received aspirin and oxycodone (Percodan; 1 tablet) PO an hour before going to radiology.
b. 1215 hrs: I gave the client morphine 10 mg IM at 1110 hours, but did not docu-ment it then.
c. 1445 hrs: Acetaminophen 500 mg given for temperature of 38.1C.
d. 2030 hrs: Abdominal dressing change at 1930 hrs. No s/s of infection, and wound edges approximating well.

Question 2

Guidelines should be followed when documenting client care. Which one of the following does the nurse recognize as the most appropriate notation?

a. 1230 hrs: Client's vital signs taken
b. 0700 hrs: Client drank adequate amount of fluids
c. 0900 hrs: Morphine given for lower abdominal pain
d. 0830 hrs: Increased intravenous (IV) fluid rate to 100 mL per hour according to protocol

xiazhe · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
1445 hrs: Acetaminophen 500 mg given for temperature of 38.1C is the best example of a late entry. The time is indicated along with the action and an objective observation.
The notation 2030 hrs: Client received aspirin and oxycodone (Percodan; 1 tablet) PO an hour before going to radiology is not complete. It does not indicate why the aspirin and oxycodone (Percodan) were given (i.e., What was the client's level of pain? Where was the pain located?).
The nurse does not need to document about himself or herself, only about the client. In the entry 1215 hrs: I gave the client morphine 10 mg IM at 1110 hours, but did not document it then, the nurse does not indicate why the morphine was given (i.e., What was the client's level of pain? Where was the pain located?).
The entry 2030 hrs: Abdominal dressing change at 1930 hrs. No s/s of infection, and wound edges approximating well is not complete. It does not state the size of the wound, type of dress-ing used, or the client's tolerance of the procedure.

Answer to Question 2

D
Information within a recorded entry must be complete, containing appropriate and essential in-formation. The notation 0830 hrs: Increased intravenous (IV) fluid rate to 100 mL per hour ac-cording to protocol provides the time and action taken by the nurse, including the reason for doing so.
The entry 1230 hrs: Client's vital signs taken does not indicate what the client's vital signs were.
The entry 0700 hrs: Client drank adequate amount of fluids does not provide the specific amount that the client drank. Stating adequate is subjective, not objective.
The notation 0900 hrs: Morphine given for lower abdominal pain does not have the client de-scribe his or her pain or rate it according to a pain scale for comparison later. It also does not in-dicate whether the client's pain was in the lower left or lower right quadrant, or both.