After your prompt intervention, you need to document what happened. Write an example of
a documentation entry describing this event.
What will be an ideal response?
Answers will vary but should include items in this note:
Time: 2000 . Pulse 120, BP 100/50 . Moderate amount of lochia rubra noted, with small clots,
underneath patient's buttocks. Fundus boggy; massaged until firm. Patient encouraged to increase
fluid intake. Voiding without difficulty. Assisted with hygiene and clean peri-pad placed. Continue to
monitor.
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A patient develops a fever, rash, joint and muscle pain, and swollen lymph nodes after receiving a sulfonamide for a urinary tract infection (UTI). The nurse anticipates providing care for which condition?
1. Serum sickness 2. Worsening of the infection 3. Respiratory involvement from systemic release of pathogens 4. Subacute rheumatoid arthritis from increased serum uric acid
A 22-year-old male client says he is attracted to persons of the same sex only. How should the nurse document his stated sexual orientation?
A) Heterosexual B) Asexual C) Homosexual D) Lesbian
A nurse is examining different nursing roles. Which statement best illustrates an advanced practice nursing role?
1. A registered nurse who is the manager of a large obstetric unit 2. A clinical nurse specialist working as a staff nurse on a mother–baby unit 3. A registered nurse who is the circulating nurse at surgical deliveries (cesarean sections) 4. A clinical nurse specialist with whom other nurses consult for this nurse's expertise in caring for high-risk infants
The nurse needs to assess the body temperature of a client who has just smoked a cigarette and drunk hot coffee. The assessment method that the nurse should use would be:
1. Rectal. 2. Tympanic. 3. Temporal artery. 4. Axillary.