The nurse wants to adhere to practice guidelines that meet legal ...

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The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care. Which actions should the nurse take to prove adherence?
 
  1. Charting the client's response to pain medication taken
  2. Describing the client as appearing to be comfortable
  3. Leaving sufficient charting space for the previous shift to chart client teaching
  4. Documenting that the client reports, I'm so afraid of tomorrow's surgery
  5. Making a late entry regarding a client's request for pain medication

Question 2

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, in which section should the nurse document this information?
 
  1. Data (D)
  2. Action (A)
  3. Response (R)
  4. Planning (P)

[ricroger]

Answer to Question 1

Correct Answer: 1, 4, 5
Rationale: Documentation guidelines include charting a change in a client's condition and showing that follow-up actions were taken.

Answer to Question 2

Correct Answer: 3
Rationale 1: The data (D) section reflects the assessment phase of the nursing process, and consists of observations of client status and behaviors, including data from flow sheets.
Rationale 2: The action (A) category reflects planning and implementation, and includes immediate and future nursing action.
Rationale 3: The response (R) category reflects the evaluation phase of the nursing process, and describes the client's response to any nursing and medical care.
Rationale 4: Planning is a subcategory of the action (A) category.

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TYSM

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Excellent