Guidelines should be followed when documenting client care. Which one of the following does the nurse recognize as the most appropriate notation?

Question

a. "1230 hrs: Client's vital signs taken"
b. "0700 hrs: Client drank adequate amount of fluids"
c. "0900 hrs: Morphine given for lower abdominal pain"
d. "0830 hrs: Increased intravenous (IV) fluid rate to 100 mL per hour according to protocol"

Answer 1

D
Information within a recorded entry must be complete, containing appropriate and essential in-formation. The notation "0830 hrs: Increased intravenous (IV) fluid rate to 100 mL per hour ac-cording to protocol" provides the time and action taken by the nurse, including the reason for doing so.
The entry "1230 hrs: Client's vital signs taken" does not indicate what the client's vital signs were.
The entry "0700 hrs: Client drank adequate amount of fluids" does not provide the specific amount that the client drank. Stating "adequate" is subjective, not objective.
The notation "0900 hrs: Morphine given for lower abdominal pain" does not have the client de-scribe his or her pain or rate it according to a pain scale for comparison later. It also does not in-dicate whether the client's pain was in the lower left or lower right quadrant, or both.