A charge nurse is reviewing documentation in the medical record from a newly licensed nurse. Click to highlight the findings that indicate this nurse requires additional education.

This question asks which documentation entries indicate the newly licensed nurse needs additional education. Three entries are problematic. The entry stating 'Morphine 10 mg IV given orally' is a critical medication administration error — morphine prescribed as IV cannot be given orally, and documenting these as the same route is factually incorrect and potentially dangerous; this indicates a serious knowledge gap. The entry describing the client as 'inappropriate and is a huge fall risk' uses subjective, unprofessional, and value-laden language rather than objective clinical observations. Professional nursing documentation must describe specific behaviors using objective, measurable language such as 'client attempted to climb out of bed twice' rather than labeling the person as 'inappropriate.' The entry recording the partner's comment that 'their spouse is always complaining or arguing' is irrelevant, subjective hearsay, and violates the client's dignity; it should not appear in the medical record. The other entries — noting the mechanism of injury, the client's history, previous hospitalizations, current mental status, pain level, activity, and provider communications — are factual, clinically relevant, and appropriately documented. The admission assessment entries about the mechanism of injury and the partner reporting depression and excessive drinking are appropriate objective history, and the provider prescription entries are not nurse-generated documentation requiring correction.