A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the newly licensed nurse indicates an understanding of the teaching?
Explanation & Rationale
A. This documentation is accurate and complete. It includes the site of measurement (radial), the rhythm (regular), and the rate (68/min), which demonstrates a clear understanding of how to document vital signs comprehensively. B. While the systolic and diastolic values and units are included, it does not specify the arm or position of the client (e.g., sitting, lying), which is important for accurate interpretation and comparison of future readings. C. Although the temperature value and units are documented, the route of measurement (oral, tympanic, axillary, rectal) is not specified. This is important because temperature readings vary depending on the site. D. The documentation includes the saturation value, but it does not include the site of measurement (e.g., finger, earlobe) or whether the client is receiving supplemental oxygen, which are important for context and accurate assessment.