A nurse is reviewing the guidelines for documenting client care.

Which of the following actions should the nurse plan to take?

Avoid quoting client comments when documenting.

Limit documentation to subjective information.

Document giving a dose of pain medication just prior to administration.

Document information telephoned in by a nurse who left the unit for the day.

Answer and Explanation

The Correct Answer is A

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.

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Correct Answer is C

Explanation

Explanation

C. Epistaxis

Heparin is an anticoagulant medication used to prevent blood clot formation. One of the potential adverse effects of heparin therapy is bleeding. Epistaxis, or nosebleeds, can be a sign of abnormal bleeding and should be reported to the provider for further evaluation and adjustment of the treatment plan if necessary.

Weight gain in (option A) is not a common adverse effect of heparin. Weight gain can be caused by various factors, but it is not directly related to heparin administration.

Bradycardia (slow heart rate) in (option B) is not a common adverse effect of heparin. Bradycardia can be caused by other factors unrelated to heparin therapy and should be evaluated separately.

Anorexia (loss of appetite) in (option D) is not typically associated with heparin therapy. Anorexia can have various causes, but it is not directly linked to heparin administration.

Therefore, the nurse should report the occurrence of epistaxis (option C) to the healthcare provider as a potential adverse effect of heparin therapy in the client.

A. Family medical history B. Medical health insurance claims C. Medications taken prior to admission D. Physical assessment findings

Correct Answer is D

Explanation

Including the client's physical assessment findings will provide important information to the physical therapist regarding the client's current condition, limitations, and areas that require rehabilitation or therapy.

While family medical history is important for comprehensive healthcare, it may not be specifically relevant to the referral for a physical therapist unless there is a specific genetic or familial condition that could impact the therapy or rehabilitation process.

Medical health insurance claims are primarily related to billing and reimbursement and may not provide pertinent information to the physical therapist unless there are specific coverage limitations or requirements that need to be considered.

While medication history is important for overall healthcare management, it may not be directly relevant to the referral for a physical therapist unless there are specific medications that could affect the therapy or rehabilitation process (e.g., medications that may cause drowsiness or affect balance).

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A nurse is reviewing the guidelines for documenting client care.

Which of the following actions should the nurse plan to take?