Author Question: Which of the following is the best example of objective charting? a. The patient states that he ... (Read 107 times)

KWilfred · **on:** Jul 24, 2018

Which of the following is the best example of objective charting?

a. The patient states that he has been having severe chest discomfort.
b. The patient is lying in bed and seems to be in considerable pain.
c. The patient appears to be pale and diaphoretic and complains of nausea.
d. The patient's skin is ashen and respiratory rate is 32 and labored.

Question 2

What should the nurse do to prevent a patient from aspirating during a seizure?

a. Insert an oral airway.
b. Restrain the patient securely.
c. Sit the patient upright.
d. Turn the patient onto his/her side.

Missbam101 · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

D
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as respiratory rate 20 and unlabored. Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient's exact words whenever possible. For example, you record, Patient states, my stomach hurts.' Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description the patient seems to be in pain does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts.

Answer to Question 2

D
If possible, turn the patient onto the side, with the head flexed slightly forward. This position prevents the tongue from blocking the airway and promotes drainage of secretions, thus reducing the risk for aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patient's mouth when the teeth are clenched. This could cause injury to the mouth and could stimulate gagging, leading to possible aspiration. Do not restrain the patient. Loosen clothing to prevent musculoskeletal injury and airway obstruction. When a seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse's lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position.