A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

A.The client's complaint of upper chest discomfort and coughing up thick clear sputum suggests a potential respiratory issue. Checking oxygen saturation is crucial to assess for possible respiratory distress or hypoxia.

B.Tremors are a chronic symptom associated with Parkinson's disease in this client. While monitoring tremors is important for assessing Parkinson's disease management, they are not an acute issue requiring immediate follow-up in this scenario.

C.Coughing up thick clear sputum and upper chest discomfort indicate potential respiratory distress or infection. Monitoring the respiratory rate helps assess the severity of respiratory distress or compromise.

D.Heart rate is a vital sign that can indicate cardiovascular status and response to the client's reported symptoms of feeling bad. Elevated heart rate may indicate stress, pain, or cardiac involvement.

E.The client is reported as alert and oriented to self. While changes in level of consciousness are always important to monitor, the client's current alert and oriented state suggests no immediate acute change.

F.Chronic health conditions such as Parkinson's disease and anxiety are part of the client's history but are not acute findings that require immediate follow-up compared to the acute symptoms of upper chest discomfort and respiratory distress reported.

Quoting client comments verbatim in the documentation should be avoided. Instead, the nurse should summarize or paraphrase the relevant information provided by the client. This helps to maintain confidentiality and professionalism in the documentation process.

Documenting giving a dose of pain medication just prior to administration: Documentation should accurately reflect the timing and administration of medications. It is not appropriate to document giving a dose of medication just prior to administering it, as it would not provide an accurate account of the client's care. The medication administration should be documented after it has been given.

Limiting documentation to subjective information: Documentation should include both objective and subjective information. Objective information refers to measurable and observable data, while subjective information represents the client's thoughts, feelings, and experiences.

Including both types of information provides a comprehensive view of the client's condition and the care provided.

Documenting information telephoned in by a nurse who left the unit for the day: Documentation should only include information that has been directly observed or obtained by the nurse providing care. It is not appropriate to document information telephoned in by a nurse who is not present and available to verify or provide additional details. Each nurse should be responsible for documenting their own observations and actions.

Accurate and comprehensive documentation is crucial for maintaining continuity of care, ensuring effective communication among the healthcare team, and promoting the client's safety and well-being. Nurses should adhere to institutional policies and guidelines regarding documentation practices and prioritize accuracy, confidentiality, and professionalism in their documentation.