Which documentation by the nurse best describes patient data?
a. "Moderate amount of clear yellow urine voided."
b. "Voided 220 mL clear yellow urine."
c. "A small amount of urine voided into absorbent pad."
d. "Patient incontinent of urine."
B
The use of precise measurements makes documentation more accurate. For example, documenting "Voided 450 mL clear urine" is more accurate than "Voided an adequate amount." Small and moderate are not as accurate as precise measurement. Patient incontinent of urine does not tell how much and although accurate is not as accurate as a precise measurement.
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A nurse is well aware of the high incidence and prevalence of chronic conditions among older adults. The nurse would recognize which of the following phenomena as currently contributing to this high rate of incidence? (Select all that apply.)
A) Longevity is increasing. B) Many previously fatal diseases are now treatable. C) Increasing numbers of older adults can afford medical care. D) Older adults have increased expectations for treatment. E) New chronic conditions are being identified by medical researchers.
The nurse charts signs of infected phlebitis as:
1. rupture of the cannula with a lump under the skin. 2. pale, cool skin with swelling at the puncture site. 3. firm, cool, raised, painful area at the puncture site; oozing; and purulent drainage 4. puncture site red, warm, with an oozing drainage.
As part of their teaching function at discharge, nurses should tell parents that the baby's respiration should be protected by all of the following procedures except:
a. Preventing exposure to people with upper respiratory tract infections. b. Keeping the infant away from secondhand smoke. c. Avoiding loose bedding, water beds, and beanbag chairs. d. Not letting the infant sleep on his or her back.
An infant at 36 weeks' gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58 mg/dL. What is the priority nursing action based on this reading?
a. Document the finding in the newborn's chart. b. Double-wrap the newborn under a warming unit. c. Feed the newborn a 10% dextrose solution. d. Notify the neonatal intensive care unit (NICU) of the pending admission.