The nurse is preparing to document care provided to a client who received rescue breathing while being transported to radiology. What should the nurse include in the documentation for this client?
1. Date and time of event
2. Factors that precipitated the event
3. Length of time with no breathing
4. Response to rescue breathing
5. Tasks assigned to the unlicensed assistive personnel
1, 2, 3, 4
Rationale 1: When documenting this event in the medical record, the nurse will include the date and time the event occurred.
Rationale 2: When documenting this event in the medical record, the nurse will include any factors that precipitated the event.
Rationale 3: When documenting this event in the medical record, the nurse will include the length of time that the client was not breathing.
Rationale 4: When documenting this event in the medical record, the nurse will include the client's response to rescue breathing.
Rationale 5: It is unnecessary to document the tasks that were assigned to the unlicensed assistive personnel during this event.
Global Rationale: When documenting this event in the medical record, the nurse will include the date and time the event occurred, any factors that precipitated the event, the length of time that the client was not breathing, and the client's response to rescue breathing. It is unnecessary to document the tasks that were assigned to the unlicensed assistive personnel during this event.
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