The nurse is performing one of the main purposes of client records, which is to communicate with other health care providers about the client’s condition, needs, and interventions.Communication is essential for ensuring continuity and quality of care, as well as for preventing errors and misunderstandings.

Choice B is wrong because planning client care is not the purpose of reviewing client records, but rather the purpose of creating and updating them.Planning client care involves setting goals, choosing interventions, and evaluating outcomes based on the information in the client records.

Choice C is wrong because auditing health agencies is not the purpose of reviewing client records by a nurse, but rather the purpose of examining them by an external or internal agency.Auditing health agencies involves assessing the quality, efficiency, and effectiveness of health care services based on the client records.

Choice D is wrong because research is not the purpose of reviewing client records by a nurse, but rather the purpose of using them by researchers.Research involves collecting, analyzing, and interpreting data from client records to generate new knowledge, improve practice, or inform policy.

Normal ranges are not applicable in this question as it does not involve any physiological or laboratory measurements.

A. Use standardized terminology and abbreviations.This is correct because standardized terminology and abbreviations can improve communication, consistency and data collection among health care providers.

B. Include the date and time of each entry.This is correct because the date and time of each entry can provide accurate and timely information about the patient’s condition and care.

C. Delete any incorrect information with a single line.

This is wrong because deleting any incorrect information with a single line is not appropriate for electronic health records.Instead, the nurse should use the correction function of the EHR system to make any changes.

D. Sign each entry with the nurse’s name and credentials.This is correct because signing each entry with the nurse’s name and credentials can ensure accountability and responsibility for the documentation.

E. Share the password with other authorized staff.

This is correct because sharing the password with other authorized staff can facilitate access to the patient’s information when needed.However, the nurse should also protect the password and security of the EHR system by closing it when not in use and not disclosing it to unauthorized persons.

Normal ranges for date and time are based on the institution’s policy and standards.

Normal ranges for standardized terminology and abbreviations are based on the accepted sources such as NANDA, NIC, NOC, etc.

“The client is alert and oriented to person, place, and time.”

This statement provides the most relevant and current information about the client’s mental status and level of consciousness, which are important for the receiving nurse to know.

The other statements are either too vague (C), too general (B), or not a priority (D) for a transfer report.

Choice B is wrong because it does not specify the current status of the client’s hypertension and diabetes, such as blood pressure, blood glucose, medications, or complications.

This information is more appropriate for a written summary or a discharge report.

Choice C is wrong because it does not provide the actual values of the client’s vital signs, which can vary depending on the client’s condition and baseline.

The receiving nurse should know the exact numbers to monitor for any changes or abnormalities.

Choice D is wrong because it does not indicate the reason why the client needs assistance with bathing and dressing, such as mobility issues, pain, or weakness.

This information is also less urgent than the client’s mental status and vital signs.

Normal ranges for vital signs are:.

• Temperature: 36.5°C to 37.2°C (97.7°F to 99°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mm Hg.

Sources:.

“It helps us to communicate with other members of the health care team.”.

Nursing documentation is essential for clinical communication.Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care.

Choice B is wrong because reimbursement is not the primary purpose of nursing documentation, although it may be a secondary benefit.

Choice C is wrong because legal liability is not the main reason for documenting care, although it may provide evidence in case of litigation.

Choice D is wrong because quality improvement is not the direct result of nursing documentation, although it may be facilitated by it.

Nursing documentation should follow six essential principles: documentation characteristics, education and training, policies and procedures, protection systems, documentation entries and standardized terminologies.

These principles help nurses to create clear, accurate and accessible records that can improve patient outcomes and safety.

: ANA’s Principles for Nursing Documentation - ANA Enterprise: Clinical Guidelines (Nursing) : Nursing Documentation Principles.

Client records.

This is because client records contain objective and measurable data on the wound healing process, such as size, depth, drainage, infection, and pain.

Client records are also reliable and valid sources of data that can be easily accessed and compared.

Choice B is wrong because client interviews are subjective and may not reflect the actual effectiveness of the wound dressing.

Client interviews may also be influenced by factors such as mood, recall, and rapport.

Choice C is wrong because client surveys are also subjective and may not capture the relevant aspects of wound healing.

Client surveys may also have low response rates or biased responses.

Choice D is wrong because client observations are not enough to evaluate the effectiveness of a wound dressing.

Client observations may be affected by personal preferences, expectations, or beliefs.

Normal ranges for wound healing depend on various factors such as the type, location, and severity of the wound, the patient’s age, health status, and nutrition, and the type of dressing used.

However, some general guidelines are:.

• Acute wounds (such as surgical incisions) should heal within 2 to 4 weeks.

• Chronic wounds (such as pressure ulcers) may take longer than 6 weeks to heal.

• Wounds should show signs of improvement such as reduced size, decreased drainage, decreased inflammation, and increased granulation tissue within 2 weeks of treatment.

Sources:.

• Wound Healing - an overview | ScienceDirect Topics.