The nurse is documenting care provided to a client with heart failure. What should be included in this documentation? (Select all that apply.)
1. Referral to dietitian
2. Treatment measures
3. Assessment findings
4. Subjective statements
5. Number of questions asked
Answer: 1, 2, 3, 4
1. Document referrals made such as to a dietitian.
2. Document treatment measures implemented and the patient's response to treatment.
3. Document assessment findings, noting any changes that occur with activity.
4. Document subjective data such as statements of improved ease of breathing.
5. The number of questions asked the client does not need to be documented.
You might also like to view...
The nurse is caring for a 1-month-old girl with low-set ears and severe hypotonia who was diagnosed with trisomy 18 . Which nursing diagnosis would the nurse identify as most likely?
A) Interrupted family process related to the child's diagnosis B) Deficient knowledge deficit related to the genetic disorder C) Grieving related to the child's poor prognosis D) Ineffective coping related to stress of providing care
The nurse is planning care for a newborn infant. In planning the diet, the nurse knows the infant will need how many kcal per day to meet energy needs for growth and development?
A) 80 to 90 kcal/kg/day B) 100 to 115 kcal/kg/day C) 120 to 130 kcal/kg/day D) 140 to 150 kcal/kg/day
The client recently diagnosed with hypertension presents with the following assessment data: weight, 200 lb; height, 5'4"; diet, mostly starches; alcohol intake, three beers/week; stressors, works 60 hours/week
In planning care with this client, what is the priority outcome? 1. The client will eliminate alcohol from the diet. 2. The client will decrease stress by limiting work to 40 hours/week. 3. The client will achieve and maintain optimum weight. 4. The client will balance diet according to the food pyramid.
The maternity nurse understands that vascular volume increases 40% to 60% during pregnancy to:
a. Compensate for decreased renal plasma flow. b. Provide adequate perfusion of the placenta. c. Eliminate metabolic wastes of the mother. d. Prevent maternal and fetal dehydration.