into his chair
C. The nurse should not document this info because she did not witness
D. The client fell in the shower & is now resting comfortably
14. A nursing instructor is reviewing documentation w/a group of
nursing students. Which of the following legal guidelines should they
follow when documenting a client's record? Select all.
The skin barrier covering a client's intestinal fistula keeps falling off
when she stands up to ambulate. The nurse has reapplied it twice
during the shift, but it remains intact only when the client is supine in
bed. The nurse telephoned the physical therapist about the difficulties
containing the drainage from the fistula, so the therapist didn't
ambulate the client today. The client sat in a chair during lunch w/an
absorbent pad over the fistula. The client ate all the food on her tray.
The wound care nurse confirmed that she will see the client later
today. The client states she feels frustrated at not having physical
therapy, but the nurse thinks the client welcomed having a day to rest.
Which of the following information should the nurse include in the
change-of-shift report? Select all.