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A nurse is charting. Which information is critical for the nurse to document?

a.The patient had a good day with no complaints.

b.The family is demanding and argumentative.

c.The patient received a pain medication, Lortab.

d.The family is poor and had to go on welfare.

1 Answer

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Final answer:

The most critical information to document when a nurse is charting is that the patient received a pain medication, specifically Lortab. This documentation is vital for continuity of care, monitoring the patient's response, and for legal and regulatory compliance.

Step-by-step explanation:

The critical information for a nurse to document when charting is centered around patient care and treatment. Of the options provided, the fact that the patient received a pain medication, Lortab, is the most critical to document. This is essential for several reasons:

  • It is a part of the patient's medical record and is necessary for continuity of care.
  • To monitor the patient's response to the medication and any potential side effects or adverse reactions.
  • For legal and regulatory purposes, as it is a controlled substance and requires accurate documentation.

Information about the patient's family's socioeconomic status or demeanor is less crucial from a clinical perspective and may be deemed irrelevant or even inappropriate to chart, unless it directly affects patient care.

User Dmitry Negoda
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