A nurse is caring for a client who had an open cholecystectomy 24 hours ago.

The client’s vital signs have been stable over the last 24 hours, with the most recent temperature

98.6° F(37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and pulse 78/min, but are now changing.

Which set of vital signs indicates that the nurse should contact the health care provider?

It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.

Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.

Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.

Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.

This is because the nurse’s reply does not address the client’s fear of radiation therapy, but rather provides factual information that may not be relevant or helpful to the client.

The nurse is not using a therapeutic communication technique, such as reflecting, exploring, or validating the client’s feelings.

Instead, the nurse is shutting down the communication and missing an opportunity to learn more about the client’s concerns and needs.

Choice A is wrong because the nurse is not confronting a painful subject, but rather avoiding it.

The nurse is not acknowledging the client’s fear or inviting the client to talk more about it.

Choice C is wrong because the nurse is not recognizing that the client needs information, but rather assuming that the client does.

The nurse is not asking the client what he or she wants to know about radiation therapy, but rather telling the client what he or she should know.

Choice D is wrong because the nurse is not perceiving that the client is ready to hear more about the treatment, but rather imposing information on the client.

The nurse is not assessing the client’s readiness to learn, but rather giving unsolicited advice.