Which entry should the nurse include in her charting? Select all ...

[dejastew]

Which entry should the nurse include in her charting? Select all that apply.
 
  A) The nursing assistant reports the client's breath smelled of alcohol.
  B) I feel something is going on she is not telling me.
  C) The client was overheard telling his family about more bleeding than he has reported to his physician.
  D) The incision is oozing a small amount of red blood.
  E) The client's pupils are dilated.

Question 2

Which statement describes best practices for charting? Select all that apply.
 
  A) Use long narratives to be sure your documentation is understood.
  B) Always use complete sentences.
  C) Use only approved abbreviations.
  D) Always use the client's name and words referring to the client in each entry.
  E) Use partial sentences and phrases.

[SVictor]

Answer to Question 1

Ans: A, C, D, E
Feedback:
Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

Answer to Question 2

Ans: C, E
Feedback:
Good charting is concise and brief. In narratives, use partial sentences and phrases; drop the client's name and terms, referring to the client. Use abbreviations but only those that are commonly accepted and approved by your facility.

[dejastew]

Excellent

[Jossy]

Gracias!