A nurse is charting. Which information is critical for the nurse to document?
a. The patient had a good day with no complaints.
b. The family is demanding and argumentative.
c. The patient received a pain medication, Lortab.
d. The family is poor and had to go on welfare.
ANS: C
Nursing interventions and treatments (e.g., medication administration) must be documented. Avoid using generalized, empty phrases such as "status unchanged" or "had good day." Do not document retaliatory or critical comments about a patient, like demanding and argumentative. Family is poor is not critical information to chart.
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