A nurse is preparing to administer medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh?

(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

The correct answer is choice A: "Complained about having incisional pain."

Choice A rationale:

Documenting a client's complaints about pain, especially incisional pain, is crucial in an electronic health record. Pain assessment and management are essential aspects of client care, and including this information helps to track the client's pain level, the effectiveness of pain interventions, and any changes in their condition over time.

Choice B rationale:

While it's important to monitor fluid intake and output, stating that the client "Voided adequate amounts through the shift" might be relevant to the client's overall condition but lacks specific information. It doesn't address the reason for the assessment, and the focus should be on the client's immediate care needs and responses.

Choice C rationale:

Noting that the client "Became short of breath when ambulating" is significant for documenting any potential signs of respiratory distress during activity. This information provides valuable insights into the client's ability to tolerate physical exertion and might indicate a need for further assessment or interventions.

Choice D rationale:

Documenting that the client "Appeared to be sleeping while in bed" might not offer significant clinical information unless there is a specific reason for noting the client's sleep patterns. Sleep is an important aspect of recovery, but this choice lacks the context needed to make it a priority entry in the documentation.

The correct answer is choice B: "Please don't tell my doctor, but I am taking my partner's oxycodone."

Choice B rationale:

This statement presents an ethical dilemma as it reveals the client's engagement in potentially harmful and illegal behavior – taking a controlled substance prescribed for someone else. The nurse must balance the duty to respect the client's confidentiality with the responsibility to address potential harm to the client and others involved.

Choice A rationale:

"I might file a lawsuit because of how my surgery went" does not present an ethical dilemma, but rather a legal concern. While the nurse should listen to the client's complaints and provide appropriate support, this statement is more related to the client's dissatisfaction with their medical care.

Choice C rationale:

"Please don't get me out of bed this morning, It hurts too much" reflects a client's pain management request. While pain management is important, this statement doesn't raise an ethical dilemma on its own. It's within the scope of care to address pain and comfort concerns.

Choice D rationale:

"I don't want to take my medicine. It makes me sick to my stomach" highlights a client's concern about medication side effects. While addressing medication concerns is essential, this statement doesn't inherently pose an ethical dilemma.