The nurse is documenting care for a client who required wound care requiring sterile technique. Which items will the nurse include in the documentation in the medical record for this client?
1. The use of sterile skill during the wound care
2. The number and type of sterile supplies available for the next provider
3. The location and appearance of the wound
4. The client's tolerance of the procedure
5. The role of the unlicensed assistive personnel (UAP) in maintaining sterile technique
Standard Text: Select all that apply.
Correct Answer: 1,3,4
The nurse must document the use of sterile skill when performing wound care that requires sterile technique. The nurse would also include documentation of the size and appearance of the wound and how the client tolerated the procedure. It is not necessary to include which sterile supplies are available for the next provider. The nurse cannot delegate the maintenance of the sterile field and sterile technique to the UAP.
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