A charge nurse is providing teaching to a newly licensed nurse on the advantages of electronic documentation. Which of the following information should the nurse include in the teaching?

A. Fairness. Fairness involves providing equitable and unbiased care to all patients. While fairness is a crucial aspect of nursing ethics, checking a client’s response to pain medication is more aligned with the nurse’s duty to follow through on patient care responsibilities.

B. Confidence. Confidence refers to a nurse’s self-assurance in their clinical skills and decision-making. Although confidence is important in nursing practice, evaluating a medication’s effectiveness is more about fulfilling a professional duty rather than demonstrating confidence.

C. Responsibility. Responsibility involves following through on nursing interventions and ensuring patient safety. By checking on the client to evaluate the effectiveness of a pain medication, the nurse is demonstrating accountability for patient care and adherence to proper nursing practice.

D. Advocacy. Advocacy involves speaking up for a patient’s rights, ensuring they receive appropriate care, and supporting their well-being. While assessing pain relief can contribute to advocacy, in this case, the nurse is primarily fulfilling their professional responsibility in medication administration and follow-up.

A. T 38.6° C (101.5°F), oral. The client’s temperature has increased, which may indicate that the infection is progressing despite treatment. Persistent fever can contribute to dehydration, increased metabolic demand, and worsening systemic inflammation, all of which require further assessment and potential intervention.

B. Apical HR 108/min. The client’s heart rate has risen from 99/min to 108/min, which may be a compensatory response to fever, infection, or early signs of sepsis. Tachycardia combined with hypotension warrants close monitoring for worsening hemodynamic instability.

C. BP 112/54 mm Hg, supine. The blood pressure has decreased from 114/56 mm Hg to 112/54 mm Hg. While this is still within an acceptable range for some clients, the low diastolic pressure may indicate vasodilation due to sepsis or dehydration. If this trend continues or the client becomes symptomatic (e.g., dizziness, altered mental status), further intervention may be needed.

D. R 22/min. The respiratory rate has decreased from 32/min to 22/min, indicating improved respiratory status with oxygen therapy. This does not require follow-up as it falls within the normal range (12-20/min) and suggests a positive response to treatment.

E. Pulse oximetry 95% on 40% O₂ via face mask. The oxygen saturation has improved significantly from 85% on room air to 95% on supplemental oxygen. This suggests that oxygen therapy is effective, and no immediate follow-up is needed for this parameter.

F. Mucous membranes pink. The improvement from pale to pink mucous membranes indicates better oxygenation and perfusion, likely due to supplemental oxygen and improved respiratory function. This is a positive finding that does not require further intervention.