[Answer] During the course of a busy shift a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid the physician removes the drain. When the nurse arrives for work the next morning she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take?

Answer: Notify the physician of the documentation omission.

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During the course of a busy shift a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid the physician removes the drain. When the nurse arrives for work the next morning she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take? An expected client outcome is The client will remain free of infection by discharge. When evaluating the client's progress the nurse notes the client's vital signs are within normal limits the white blood cell count is 12 000 and the client's abdominal wound has a … How should the nurse document this abnormal assessment finding? ... The night shift nurse notes that the patient's urine output has been 700 mL during the night shift while it was more than 1500 mL of clear yellow urine during the day shift . ... and headache experiences an increase in body weight and blood pressure . The nurse anticipates that ... The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a re...

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