While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes serosanguineous drainage on the patient's dressing. Which statement should the nurse use to document the finding?
a. "Normal drainage noted."
b. "Moderate drainage recently noted."
c. "Scant serosanguineous drainage seen on dressing."
d. "Pale pink drainage, 2 cm by 1 cm, noted on dressing."
ANS: D
D. Objective data are pieces of factual information obtained through physical assessment and diagnostic tests observable or knowable through the five senses. The nurse should document exactly what is seen. A. B. C. These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting.
You might also like to view...
The patient is being sent home from the hospital after a cardiac catheterization. What should the nurse instruct the patient to do first if bleeding should occur at the femoral artery puncture site?
a. Call the physician. b. Call 9-1-1. c. Apply pressure to the site. d. Apply a new bandage.
A nurse is scheduled to receive a new client with stage 2 Alzheimer disease. When planning for this client's care, the nurse recalls that the symptom most associated with stage 2 of Alzheimer disease is:
A) Mild memory loss. B) Disorientation concerning time and events. C) Disorientation concerning persons, places, or things. D) A reduction in the gag and swallowing reflex.
A nurse performs a variety of tasks as part of the nurse's position at a hospital. Which task best exemplifies public health?
A) Reading current nursing journals and integrating the latest research into daily practice B) Instructing a client on how to best care for a suture site at home C) Participating in a videoconference call with a client who lives in a remote area D) Facilitating a community-wide smoking cessation program one month out of the year
A nurse is assessing a newborn who is about 4½ hours old. The nurse would expect this newborn to exhibit which of the following? (Select all that apply.)
A) Sleeping B) Interest in environmental stimuli C) Passage of meconium D) Difficulty arousing the newborn E) Spontaneous Moro reflexes