Question

A nurse is caring for a client who received 0.9% NaCl 1L over 4 hr instead of over 8 hr as prescribed. Which of the following information should the nurse enter as a complete documentation of the incident?

1. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
2. 0.9% NaCl 1L IV infused over 4 hr. Vital signs stable, provider notified.
3. 1L of 0.9% NaCl completed at 0900. Client denies shortness of breath.
4. IV fluid initiated at 0500. Lungs clear to auscultation.

Answer 1

Option 2 should be entered as the complete documentation of the incident. It provides specific information about the IV fluid, duration of infusion, vital signs, and notification of the provider.

Step-by-step explanation:

The nurse should enter option 2 as the complete documentation of the incident. This option provides specific information about the IV fluid (0.9% NaCl 1L) and the duration of infusion (4 hours). It also states that the client's vital signs were stable, and the provider was notified. This documentation accurately captures the situation and the actions taken by the nurse.