Guidelines should be followed when documenting client care. The nurse recognizes that the following is the most appropriate notation:
A. 1230 Client's vital signs taken
B. 0700 Client drank adequate amount of fluids
C. 0900 Meperidine (Demerol) given for lower abdominal pain
D. 0830 Increased intravenous (IV) fluid rate to 100 ml/hour according to protocol
D
D. Information within a recorded entry must be complete, containing appropriate and essential information. This notation provides the time and action taken by the nurse, including the reason for doing so.
A. This entry does not indicate what the vital signs were.
B. This entry does not provide a specific amount the client drank. Stating "adequate" is subjective, not objective.
C. This notation does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the client's pain was in the lower left or lower right quadrant, or both.
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