A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

A) Place the client in a supine position:

Placing a client with pulmonary edema in a supine position can exacerbate symptoms by increasing venous return and worsening fluid accumulation in the lungs. Instead, positioning the client upright or in a semi-Fowler's position is more appropriate to facilitate respiratory mechanics and decrease venous return.

B) Weigh the client every other day:

Daily weight monitoring is crucial for clients with pulmonary edema to assess fluid balance accurately. Weighing the client every other day may not provide timely information on fluid retention and response to treatment. Therefore, daily weight measurement is typically recommended.

C) Encourage the client to ambulate three times per day:

While mobility is essential for overall health, clients with pulmonary edema may experience dyspnea and fatigue, limiting their ability to ambulate. Ambulation should be encouraged but should be tailored to the client's tolerance level and may need to be adjusted based on their respiratory status.

D) Report urine output less than 30 mL/hr:

Monitoring urine output is vital in clients with pulmonary edema to assess kidney perfusion and fluid balance. A urine output of less than 30 mL/hr may indicate decreased renal perfusion and impaired fluid clearance, which can exacerbate pulmonary congestion. Therefore, it is crucial to report such findings promptly for further evaluation and intervention.

A) Determine possible alternatives:

After identifying the ethical problem, determining possible alternatives comes later in the ethical reasoning process. This step involves brainstorming potential courses of action or solutions to address the ethical dilemma.

B) Examine the outcomes:

Examining the outcomes occurs after identifying possible alternatives. In this step, the nurse evaluates the potential consequences or outcomes of each alternative to determine which course of action aligns best with ethical principles and achieves the desired goals.

C) Develop a plan of action:

Developing a plan of action is a subsequent step in the ethical reasoning process, following the identification of the problem and consideration of possible alternatives. Once the nurse has evaluated the outcomes of various options, they can formulate a plan that outlines the chosen course of action and its implementation steps.

D) Identify the problem:

Identifying the problem is the first step in the ethical reasoning process. This involves recognizing the presence of an ethical dilemma or issue that requires resolution. By clearly defining the problem, the nurse can begin to explore relevant ethical principles, values, and considerations to guide decision-making and problem-solving.