A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion?
1. Latest body temperature
2. Type of solution and flow rate
3. Total intravenous intake for the shift
4. Status of the intravenous catheter site
5. Results of blood pressure measurement
Correct Answer: 2, 3, 4
Rationale 1: Body temperature may help determine fluid status; however, this is not documented in the medical record related to the client's continuous intravenous fluid infusion.
Rationale 2: The type of solution and flow rate should be documented.
Rationale 3: Total intravenous intake for the shift should be documented according to agency policy.
Rationale 4: The status of the intravenous insertion site should be documented.
Rationale 5: Blood pressure may help determine fluid status; however, this is not documented in the medical record related to the client's continuous intravenous fluid infusion.
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