The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

A. Signs of fluid overload: Fluid overload presents with edema, crackles in lungs, and increased blood pressure, not dry skin and mucous membranes.

B. Symptoms: Symptoms are subjective (e.g., pain, nausea), while the given findings are observable signs.

C. Data clustering: The nurse groups related signs (flushed skin, dry mucous membranes, elevated temperature) to identify a pattern suggesting dehydration or fever.

D. Urinary retention: Urinary retention is associated with bladder distention and reduced urine output, not dry skin and mucous membranes.

A. Every facility should have an approved abbreviations list. Hospitals and healthcare settings maintain a list of approved abbreviations to ensure consistency and prevent misinterpretation.

B. Creating abbreviations saves time for the person reading the chart: Unapproved abbreviations can lead to confusion and errors, potentially harming the patient.

C. Writing out questionable abbreviations could make a jury think you're hiding something: Avoiding abbreviations improves clarity, and using full words is preferred in legal documentation.

D. Abbreviating drug names and dosages helps reduce medication errors: Abbreviating drug names can cause dangerous medication errors (e.g., MS can mean morphine sulfate or magnesium sulfate). The Joint Commission prohibits certain abbreviations.