The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

Identify the two primary methods used to collect data:

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

The nurse documents in the patient record, "0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.” The most significant statement about the documentation is that it is:

Which part of the medical record can be used as evidence in court?

When documenting events in a patient's chart, the nurse should chart:

A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to: