A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

A. Respiratory acidosis is incorrect. Chronic diarrhea typically leads to metabolic acidosis, not respiratory acidosis. Metabolic acidosis occurs due to the loss of bicarbonate through diarrhea, which affects the body’s acid-base balance.

B. Hypermagnesemia is incorrect. Chronic diarrhea is more likely to lead to hypomagnesemia due to the loss of electrolytes through frequent bowel movements, not an increase in magnesium levels.

C. Hypertension is incorrect. Chronic diarrhea generally leads to dehydration and hypotension due to fluid loss rather than high blood pressure.

D. Hypokalemia is correct. Chronic diarrhea causes significant potassium loss, which can result in hypokalemia (low potassium levels). Potassium is lost in the stool, and this depletion can lead to muscle weakness, arrhythmias, and other complications.

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." This is the correct choice. The nurse should document the client's own account of the event in the medical record. It is important to accurately record the client's statement, as documentation should reflect the facts and avoid interpretation or assumptions.

B. "An incident report has been completed and sent to risk management." This statement should not be included in the client's medical record. Incident reports are separate from clinical documentation and are not part of the patient's permanent medical record.

C. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement makes an assumption about the cause of the fall and includes blame, which is inappropriate for medical documentation. Documentation should focus on objective observations and the client's statement, not assigning fault.

D. "The client does not appear to have any injuries resulting from the fall." While the nurse may assess the client for injuries, this statement should not be included unless it is confirmed and part of a thorough, objective assessment. It’s important to document specific findings (e.g., "No visible injuries noted").