A nurse is preparing to document a client's wound assessment in the electronic health record.

Which of the following actions should the nurse take?

Include the date and time of the assessment.

Rationale: The nurse should include the date and time of the wound assessment in the documentation, as this provides a chronological and accurate record of the client's condition and response to treatment.

Incorrect options:

B) Use abbreviations that are approved by the facility. - This is a partially correct statement, as the nurse should use abbreviations that are approved by the facility to ensure clarity and consistency in the documentation. However, this is not the best answer, as some abbreviations may still be confusing or ambiguous, and should be avoided or spelled out.

C) Copy and paste the previous assessment as a template. - This is an incorrect statement, as copying and pasting the previous assessment as a template can result in errors, omissions, or duplication of information, compromising the quality and integrity of the documentation.

D) Delete any inaccurate entries made by other staff members. - This is an incorrect statement, as deleting any entries made by other staff members is unethical and illegal, as it alters the original record and may affect the client's care or legal outcomes. The nurse should follow the facility's policy on correcting errors in documentation, which usually involves drawing a single line through the error, writing "error" above it, and signing and dating it.

Check the tubing for any leaks or kinks.

Rationale: The nurse should check the tubing for any leaks or kinks, as continuous bubbling in the water seal chamber indicates an air leak in the system, which can impair lung re-expansion and drainage. The nurse should locate and seal the leak, and notify the provider if necessary.

Incorrect options:

A) Clamp the chest tube near the insertion site. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and other structures. The nurse should only clamp the chest tube briefly when changing the drainage system or assessing for an air leak.

C) Increase the suction pressure to the drainage system. - This is an incorrect action, as increasing the suction pressure to the drainage system can cause damage to the lung tissue and increase the risk of infection. The nurse should follow

the provider's prescription and the manufacturer's guidelines for setting and adjusting the suction pressure.

D) Document the finding as an expected outcome. - This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document

the finding as an abnormal finding and report it to the provider.