A supervisor is reviewing the documentation of the nurses in the unit. The documentation that most accurately and correctly contains all the required parts for a narrative entry is the entry that reads:
1. "1630 Catheterized using an 8 French catheter, 45 ml clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mother's arms following catheter removal. M. May RN"
2. "1/9/05 2 P.M. g-tube accessed, positive air gurgle over stomach: 5 ml air injected, 10 ml residual stomach contents returned to stomach, Pediasure formula hung on Kangaroo pump infusing at 60 mL/hr for 1 hour. Child grunting intermittently throughout procedure. K. Earnst RN"
3. "4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. F. Luck RN"
4. "Feb. '05 Portacath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gammaglobulins hung and infusing at 30mL/hr. Child smiling and playful throughout the procedure. P. Potter, RN"
2
Rationale:
1. While the description of the procedure is appropriate, this documentation does not include the date the note was written.
2. The client record should include the date and time of entry, nursing care provided, assessments, an objective report of the client's physiologic response, exact quotes if applicable, and the nurse's signature and title.
3. This option appropriately describes the procedure but neglects to include the date and how the client tolerated it.
4. This note does not specify the exact date and time at which the portacath was accessed. It also does not include the size of Huber needle was used.
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