A nurse is documenting the data collected from an assessment of a client who has a urinary tract infection (UTI). Which of the following statements should the nurse use to record objective data?

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

Choice A reason:

The nurse checks the client's identification bracelet and verifies allergies. This is an essential component of this skill because it ensures that the nurse is performing the intervention for the right client and avoids any potential adverse reactions or interactions due to allergies.

Choice B reason:

The nurse measures the client's blood pressure in both arms and compares with previous readings. This is not an essential component of this skill because it is not directly related to the intervention for hypertension. It is a part of the assessment process that should be done before planning the intervention.

Choice C reason:

The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. This is an essential component of this skill because it helps the nurse to identify any possible factors that may affect the client's blood pressure or the effectiveness of the intervention. Some medications or supplements may interact with the prescribed drugs or alter the blood pressure level.

Choice D reason:

The nurse reviews the most current evidence and guidelines for hypertension management. This is not an essential component of this skill because it is not specific to the client's situation or needs. It is a part of the planning process that should be done before implementing the intervention.

Choice E reason:

The nurse explains the purpose, procedure, and potential side effects of the intervention to the client. This is an essential component of this skill because it respects the client's autonomy and informed consent. It also helps the client to understand what to expect and how to cope with any possible complications or discomforts.