A Supervisor Is Reviewing Documentation of the Nurses in the Unit

question 16

Multiple Choice

A supervisor is reviewing documentation of the nurses in the unit. Which client documentation is the most accurate and contains all the required part for a narrative entry?

• A) "2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mother's arms following catheter removal. M. May RN"
• B) "1/9/05 2 pm nasogastric tube placement confirmed and irrigated with 30 ml sterile water. Suction set at low, intermittent. Oxygen via nasal canal at 2 L/min. Nares patent, pink, and nonirritated. K. Earnst RN"
• C) "4:00 tracheostomy dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile tracheostomy sponge and trach ties applied. Respirations regular and even throughout the procedure. F. Luck RN"
• D) "Feb. '05 Port-A-Cath assessed with Huber needle. Blood return present. Flushed with NaCl solution, IV gamma globulins hung and infusing at 30 cc/hr. Child smiling and playful throughout the procedure. P. Potter, RN"

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Definitions:

Lowering Blood Pressure

The reduction of the force exerted by circulating blood on the walls of the body's arteries.

Macrophage Activity

Macrophage activity refers to the behaviors and functions of macrophages, which are white blood cells that engulf and digest cellular debris, foreign substances, and pathogens.

Problem-Focused Coping

A coping strategy where an individual directly tackles a problem causing stress in order to reduce or remove the stressor.

Learned Helplessness

The hopelessness and passive resignation an animal or human learns when unable to avoid repeated aversive events.