Author Question: Guidelines should be followed when documenting client care. The nurse recognizes that the following ... (Read 28 times)

asmith134 · **on:** Jul 24, 2018

Guidelines should be followed when documenting client care. The nurse recognizes that the following is the most appropriate notation:

A. 1230 Client's vital signs taken
B. 0700 Client drank adequate amount of fluids
C. 0900 Meperidine (Demerol) given for lower abdominal pain
D. 0830 Increased intravenous (IV) fluid rate to 100 ml/hour according to protocol

Question 2

The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in the throat and trachea. Which action by the nurse demonstrates proper technique?

a. Applying sterile petroleum jelly to the distal tip of the suction catheter
b. Applying clean gloves to both hands
c. Inserting the suction catheter 6 to 8 inches during inspiration
d. Suctioning the pharynx first and then the trachea

karlss · **Reply #1 on:** Jul 24, 2018

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.