Which is the most appropriate notation for a use to use according to t

Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?

1. 1230—Client’s vital signs taken.
2. 0700—Client drank adequate amount of fluids.
3. 0900—Demerol given for lower abdominal pain.
4. 0830—Increased IV fluid rate to 100 mL/hr according to protocol.

ANSWER

ANS: 4
Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating “adequate” is subjective, not objective. This notation (0900) does not have the client describe his or her pain or rate it ac-cording to a pain scale for comparison later. It also does not indicate whether the client’s pain was in the lower left or lower right quadrant, or both.