Calculate the intake for the 6 AM to 6 PM shift.

• A patient consumes 8 oz of a popsicle and 80 mL of ice chips during the shift.
• Intravenous fluids infused at 150 mL/hr during the shift.
• The Foley catheter was emptied of 800 mL at 1 AM & 925 mL at 6 PM. 80 mL were emptied from a drain at 6 PM.

Choice A rationale

"Seems lethargic" is subjective and lacks specific, measurable data. Lethargy can manifest differently in patients, and this statement doesn't provide objective evidence to support the observation. Accurate documentation requires specific descriptions of observed behavior.

Choice B rationale

"The patient was incontinent" is more direct but lacks crucial details such as the type of incontinence (urinary or fecal), the amount, and any associated factors. Comprehensive documentation would include these specifics for a clear understanding of the event.

Choice C rationale

"The patient ate 25% of a hearty meal" is relatively objective and quantifiable, providing a specific measure of the patient's intake. However, "hearty" is still somewhat subjective. Specifying the type and estimated size of the meal would enhance clarity.

Choice D rationale

"The patient voided in the urinal" is a clear, objective statement of an observable action. It specifies the method of voiding and provides a concrete piece of information about the patient's urinary function. This type of documentation is precise and unambiguous.

Choice A rationale

While nursing regulations do outline standards of care, the primary rationale for frequent repositioning and padding is not solely based on delegation limitations. Preventing pressure injuries is a fundamental nursing responsibility, regardless of who performs the tasks under appropriate supervision.

Choice B rationale

Identifying patient care areas needing additional assistance is a separate aspect of nursing assessment and care planning. While repositioning and padding contribute to overall well-being, their direct rationale is the prevention of skin breakdown, not the identification of staffing needs.

Choice C rationale

Unconscious patients are at high risk for developing pressure injuries due to immobility and decreased sensation. Repositioning at least every two hours reduces prolonged pressure on bony prominences, and padding distributes pressure more evenly, both crucial interventions in preventing tissue ischemia and subsequent ulcer formation.

Choice D rationale

While standing orders may include guidelines for repositioning and skin care, the underlying rationale stems from the physiological need to prevent pressure injuries in immobile patients. The nurse's actions are based on established principles of preventing complications associated with immobility, not solely on following pre-written orders. .