Ensuring Client Confidentiality During Documentation |

1. Nurses ensure client confidentiality during documentation by not sharing passwords, having passwords that are changed at set intervals, logging out of the chart prior to walking away, and never leaving a client’s chart up on the screen.
2. Seizure precautions the nurse should implement for this client include padding the side rails, placing an airway at the bedside, and placing oxygen and suction equipment at the bedside.
3. A nurse should submit an incident report immediately after witnessing an incident such as a fall.
4. Expected physiological changes for the older adult client include decreased skin elasticity, decreased gastric motility, and increased pain threshold.
5. A nurse should use a doppler stethoscope when peripheral pulses are nonpalpable or difficult to palpate.
6. The nurse should observe the client use the cane on the strong side of their body, ensuring the client stands with their weight evenly distributed between their feet and the cane, and the weaker leg is moved forward until even with the stronger foot along with the advancement of the cane
7. The nurse should confirm placement with an x-ray when caring for a client who just had a central venous line inserted. Once the placement is confirmed, the nurse should begin the prescribed infusion via the new access.
8. The nurse should take the following steps to interpret arterial blood gas results: Determine if acidosis or alkalosis is present, identify if the respiratory or metabolic system is responsible, and assess if the system is compensating.
9. When teaching a client about pursed-lip breathing, the nurse should instruct the client to relax their neck and shoulders, breathe normally through the nose for two counts, pucker their lips as if going to whistle, and breathe out slowly through pursed lips for four counts.