After changing the client's central line dressing, what should the nurse include when documenting this procedure?
1. Fluid infusing into the catheter
2. Assessment of the central line insertion site
3. Type of dressing applied
4. Aseptic technique under which the dressing was changed
5. Client complaints or concerns
2, 3, 4, 5
Rationale 1: The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.
Rationale 2: The nurse should document the appearance of the central line insertion site.
Rationale 3: The nurse should document the type of dressing applied.
Rationale 4: The nurse should document the aseptic technique used, such as "sterile technique used to apply Tegaderm dressing."
Rationale 5: If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client.
Global Rationale: The nurse should document the appearance of the central line insertion site, the type of dressing applied, and the aseptic technique used, such as "sterile technique used to apply Tegaderm dressing." If the client voices any concerns or complaints, the nurse would record them, along with actions taken to care for the client. The fluid infusing is documented on the IV infusion record, but not in the note regarding dressing change.
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