The nurse is caring for a trauma patient who has just arrived in the emergency room.
The nurse listens to the patient's lung sounds, palpates the patient's peripheral pulses, and obtains vital signs.
What is the best description of the nurse's actions?

Choice A rationale

This statement provides objective and descriptive information about the patient's condition following the venipuncture. It accurately describes the physical findings (painful, raised hematoma) and the location (outer left arm) and clearly links it to the medical procedure (after venipuncture) without making assumptions or assigning blame.

Choice B rationale

This statement is inappropriate as it is judgmental and accusatory towards the laboratory technician. Medical documentation should be objective and focus on the patient's condition and care, not on personal opinions or unsubstantiated claims about the skills of healthcare professionals.

Choice C rationale

This statement is speculative and attempts to explain the cause of the hematoma without factual basis. While patient movement can contribute to bruising, stating it as a likely cause without evidence is not objective documentation and could be inaccurate.

Choice D rationale

While this statement is factual in that it describes the presence of a bruise, it lacks important details such as the size, characteristics (e.g., raised, painful), and its direct association with the venipuncture, which are relevant for a comprehensive patient record.

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Speculating about the cause of the fall ("probably urinated on the floor") is unprofessional and lacks factual basis. Charting should be objective and based on observed facts, not assumptions.

Choice B rationale

Documenting objective observations, such as finding the patient on the floor with the urinal nearby, provides a factual account of the incident without making assumptions or assigning blame. This allows for a more accurate analysis of potential contributing factors.

Choice C rationale

Commenting on the nurse assistant's work habits ("always took her time") is subjective, irrelevant to the fall incident itself, and unprofessional. Charting should focus on the patient and the event.

Choice D rationale

Describing the patient as "grouchy and inappropriate" is judgmental, subjective, and does not contribute to an understanding of the fall. Such personal opinions are inappropriate for medical documentation.