The nurse enters the client's room and observes that the IV infusion device displays the correct fluid volume delivered to the client
Later, the unlicensed assistive personnel (UAP) enters the room and discovers the IV catheter is in the bed and blood is oozing from the IV puncture site. Which statement about these events is correct about nursing documentation in an incident report? 1. The UAP documents, "Nurse did not notice bloody drainage.".
2. The UAP reports to the RN, "IV catheter oozing bloody drainage.".
3. The nurse documents, "Client pulled out IV; bloody drainage in bed.".
4. The nurse documents, "IV infusing without difficulty at prescribed rate.".
2
2. The UAP reports client observations to the RN because the UAP is the first person to notice the event; however, the RN documents the event with facts.
1. The UAP avoids documenting that the RN did not notice the IV draining into the bed because the UAP does not know this to be a fact, RNs file incident reports, and members of the health care team avoid accusing other team members of wrongdoing in the medical record.
3. The nurse does not document that the client pulled out the IV because no one witnessed the event.
4. The nurse should not document that the IV is infusing without difficulty because the statement is false; it implies that the IV is infusing into the client.
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