The nurse is collecting data from the client following the transfusion of 2 units of packed RBCs.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.

Laboratory Results:

1800:

WBC count 6,700/mm (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Vital Signs:

1800:

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18/min

Temperature 37.5°  C (99.5°  F)

O2 saturation 100% 2 L/min O2 via nasal cannula

Assessment:

1800:

Physical Exam

General: no distress

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding

Neurologic: awake and alert

A. "An incident report has been completed and sent to risk management." Incident reports are used for internal facility documentation and quality improvement but should not be mentioned in the medical record. Including this information could make the report discoverable in legal proceedings, which is why it should remain separate from the client’s medical documentation.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame without objective evidence and does not follow factual documentation principles. Medical records should include observable data, client statements, and assessments rather than subjective conclusions or assumptions about the cause of the fall.
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'" Including the client's direct statement ensures accurate, objective documentation. It provides firsthand information about the incident without making assumptions or assigning blame. Client statements should always be documented using quotation marks to maintain accuracy.
D. "The client does not appear to have any injuries resulting from the fall." This statement is subjective and may be misleading. A client could have internal injuries that are not immediately visible. Instead, the nurse should document a detailed physical assessment, such as "No visible injuries noted. Client denies pain or discomfort at this time."

A. Apply water-soluble lubricant to the site. Lubricants are not necessary for gastrostomy tube site care. Instead, the nurse should keep the area clean and dry to prevent irritation and infection. Applying lubricant could increase moisture, potentially leading to skin breakdown or fungal infections.
B. Attach an extension tube to the site's opening prior to use. Extension tubes are only needed for certain types of gastrostomy devices, such as low-profile buttons, and should be attached only when feeding or administering medications. Continuous attachment is unnecessary and may increase the risk of dislodgment or contamination.
C. Tape the tube to the child's cheek. Taping a gastrostomy tube to the cheek is inappropriate, as it does not provide adequate stabilization and may cause discomfort. This technique is more commonly used for securing nasogastric tubes rather than gastrostomy tubes.
D. Secure the tubing to the child's abdomen. Properly securing the gastrostomy tube to the abdomen helps prevent accidental dislodgment, irritation, and skin breakdown. The tube should be secured with tape or a securement device while allowing slight movement to reduce tension on the insertion site.