After shift change the nurse discovers that a client's IV heparin has been turned off at the IV controller. The amount of fluid left in the IV bag indicates that the client received half of the dose ordered. Which statement should be documented in the client's medical record?
A) IV heparin restarted. Physician notified. Client's vital signs unchanged.
B) IV heparin restarted at a rate to catch up dosage accidentally deleted.
C) IV heparin turned off by previous shift. Restarted.
D) IV heparin restarted and incident report completed.

Question

Quizplus · Accepted Answer

1. The documentation in the chart should be a statement of the facts as well as the client's physical status after the incident.
2. The word "accidentally" should not be used to document incidents.
3. The nurse is not certain the IV was turned off by the previous shift, so that entry should not be used.
4. The fact that an incident report was completed should not be documented.

After Shift Change the Nurse Discovers That a Client's IV