The physician orders 350,000 units of Penicillin G IM now for a patient with a positive strep infection.

What is the most appropriate diluent amount for this patient? See LABEL #1 (Penicillin G)

Choice A rationale

This is a direct quote from the client, providing subjective data about their difficulty with the syringe markings. Documenting client statements verbatim, enclosed in quotation marks, offers valuable insight into their perspective and experiences.

Choice B rationale

This is an objective finding, reporting a specific laboratory value (Fasting Blood Sugar). Documenting numerical data with units of measurement is essential for tracking trends and assessing the client's condition. The normal range for FBS is typically 70-100 mg/dL.

Choice C rationale

This documents an observed skill and the client's ability to perform a specific task correctly. Documenting observed behaviors and skills demonstrates the client's learning and competence in self-care activities.

Choice D rationale

The phrase "seems to be more comfortable" is a subjective interpretation by the nurse rather than an objective observation or a direct client statement. Documentation should primarily focus on factual observations, client statements, and measurable data rather than the nurse's personal opinions or assumptions.

Choice A rationale

Information about the family of a client in a different room (room 107) is not directly relevant to the change-of-shift report for the client in room 108. The report should focus on information pertinent to the care of the assigned client.

Choice B rationale

While the fact that a client in room 105 had a bath might be included in their specific report, it is not essential information to communicate during the change-of-shift report for the client in room 108 who has a new pain medication.

Choice C rationale

The administration of a new pain medication to the client in room 108 is crucial information for the oncoming nurse. It is essential to communicate the name of the medication, the time it was given, the dosage, the route of administration, and the client's response to the medication to ensure continuity of pain management.

Choice D rationale

The dietary preferences of a client in a different room (room 109) are not relevant to the change-of-shift report for the client in room 108. Dietary information is specific to each client and should be communicated within their individual report if pertinent to their current care.