A nurse is caring for a client who has just undergone surgery for appendicitis.

The nurse documents in the client’s chart : “Client resting comfortably in bed with IV fluids infusing at 125 mL/hr.

Dressing clean , dry , and intact.

No complaints of pain or nausea.

Denies any problems or concerns.” This type of documentation is an example of :.

SOAP charting.

PIE charting.

Focus charting.

Narrative charting.

Answer and Explanation

The Correct Answer is D

Narrative charting.

This type of documentation is an example of narrative charting because it chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift in a descriptive format.

Some other choices are:.

• Choice A is wrong because SOAP charting is a type of documentation that is organized by four categories: Subjective, Objective, Assessment, and Plan.

It is commonly used in problem-oriented medical records.

• Choice B is wrong because PIE charting is a type of documentation that uses three categories: Problem, Intervention, and Evaluation.

It is based on the nursing process and eliminates the need for a separate care plan.

• Choice C is wrong because Focus charting is a type of documentation that uses three categories: Data, Action, and Response.

It emphasizes the patient’s concerns, problems, or strengths rather than medical diagnoses.

Normal ranges for vital signs and laboratory values may vary depending on the facility and the patient’s condition.

However, some general ranges are:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg or lower.

• Oxygen saturation: 95% or higher.

• Hemoglobin: 12 to 18 g/dL for men, 11 to 16 g/dL for women.

• Hematocrit: 37% to 49% for men, 36% to 46% for women.

• White blood cell count: 4,000 to 11,000 cells/mm3.

• Platelet count: 150,000 to 400,000 cells/mm3.

• Blood glucose: 70 to 110 mg/dL.

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Correct Answer is ["A","B","D","E"]

Explanation

The nurse should use the following abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min:.

• O2: This stands for oxygen and indicates the type of gas being delivered to the patient.

• NC: This stands for nasal cannula and indicates the device used to deliver oxygen to the patient.

• SpO2: This stands for peripheral oxygen saturation and indicates the percentage of hemoglobin that is saturated with oxygen in the blood.

It is measured by a pulse oximeter attached to the patient’s finger or earlobe.

• RR: This stands for respiratory rate and indicates the number of breaths per minute that the patient takes.

It is an important vital sign to monitor in patients with respiratory conditions.

Choice C is wrong because LPM is not an accepted abbreviation for oxygen therapy.LPM stands for liters per minute and indicates the flow rate of oxygen being delivered to the patient.However, it should not be abbreviated as LPM, but written out in full or as L/min.This is to avoid confusion with other abbreviations such as lpm (lowercase L) which stands for light per minute, a unit of luminous flux.

Normal ranges for SpO2 and RR vary depending on the age, health status and activity level of the patient, but generally they are:.

• SpO2: 95% to 100% for healthy adults.

Lower values may indicate hypoxemia (low blood oxygen level) or other conditions affecting oxygen delivery or uptake in the body.

• RR: 12 to 20 breaths per minute for healthy adults.

Higher or lower values may indicate respiratory distress, infection, pain, anxiety or other conditions affecting breathing.

A. It eliminates errors due to illegible handwriting. B. It allows access to multiple clients’ records at once. C. It reduces duplication of documentation among caregivers. D. It provides built-in safeguards to protect confidentiality.

Correct Answer is C

Explanation

It reduces duplication of documentation among caregivers.

This is an advantage of using an EHR system because it allows different healthcare providers to access and update the same record, avoiding unnecessary repetition and inconsistency.An EHR system also improves the quality and safety of care by providing clinical decision support, reducing medication errors, and facilitating communication among caregivers.

Choice A is wrong because it is not the only advantage of using an EHR system.While it is true that an EHR system eliminates errors due to illegible handwriting, it may also introduce new types of errors such as data entry mistakes, system failures, or unauthorized access.

Choice B is wrong because it is not an advantage of using an EHR system.

In fact, it may be a disadvantage because it poses a risk to the confidentiality and security of the clients’ records.An EHR system should have built-in safeguards to protect the privacy and integrity of the data, such as encryption, passwords, and audit trails.

Choice D is wrong because it is not an advantage of using an EHR system.It is a requirement of any health record system, whether electronic or paper-based, to comply with the ethical and legal standards of confidentiality.

An EHR system does not provide any additional safeguards that are not already present in a paper-based system.

Normal ranges for vital signs are as follows:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mm Hg.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is using an electronic health record (EHR) system to document care for a client who has pneumonia. Which of the following is an advantage of using an EHR system?

Correct Answer is C

Explanation

A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility. Which of the following data should the nurse record on this type of document?

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

A nurse is using the focus charting method to document care for a client who has diabetes mellitus. Which of the following terms should the nurse use to begin each entry?

A nurse is documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

Which of these statements about documentation are true? (Select all that apply.).

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?