A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?

Charting by exception (CBE).

Focus charting (DAR).

Problem-oriented medical record (POMR).

SOAP documentation.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.

Choice B rationale:

Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.

Choice C rationale:

Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.

Choice D rationale:

SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is Choice C. Secure the restraints using a quick-release tie.

Choice A rationale: Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.

Choice B rationale: Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.

Choice C rationale: Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.

Choice D rationale: Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.

A. Inform the client of the need to pre-pay for the consent of authorization. B. Contact the client's insurance carrier to obtain authorization. C. Notify the provider to obtain approval for the surgery. D. Witness the client sign the surgical consent form.

Correct Answer is B

Explanation

Choice A rationale:

The nurse should not inform the client of the need to pre-pay for the consent of authorization. Precertification for surgery is related to obtaining approval from the client's insurance provider and not about pre-payment.

Choice B rationale:

Contacting the client's insurance carrier to obtain authorization is the correct action to take when obtaining precertification for surgery. Many insurance companies require pre-authorization for surgical procedures to ensure coverage and to confirm that the procedure is medically necessary. This step is essential to prevent financial burdens on the client and ensure they have coverage for the surgery.

Choice C rationale:

Notifying the provider to obtain approval for the surgery is not the nurse's responsibility in the context of precertification. The primary responsibility lies with obtaining approval from the client's insurance carrier.

Choice D rationale:

Witnessing the client sign the surgical consent form is an essential step in the surgical preparation process but is not the same as obtaining precertification. Precertification involves confirming insurance coverage and approval for the surgery, which is the responsibility of the insurance carrier, not the client's consent.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is documenting client care including only unexpected findings related to the client's condition.Which of the following documentation methods is the nurse utilizing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is scheduling a client for surgery.Which of the following actions should the nurse take to obtain precertification for the client to have surgery?

Correct Answer is B

Explanation

A nurse is discussing a client's needs at an interdisciplinary team conference.The client had a stroke and requires inpatient rehabilitation incorporated into their plan of care.Which of the nursing competencies is the nurse demonstrating?

A nurse is caring for a client who is scheduled for surgery. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

A charge nurse is providing teaching to a nursing team member about the competencies required for interprofessional collaboration.Which of the following statements by the nursing team member indicates an understanding?

A nurse is teaching a class on ethical principles.The nurse should include that protecting a client's safety by not causing harm refers to which of the following ethical principles?

A nurse is admitting a client who speaks a different language than the nurse.Which of the following actions should the nurse take?

A charge nurse is discussing evidence-based practice (EBP) and the hierarchy of evidence with a newly licensed nurse.Which of the following examples should the nurse provide when discussing Level I evidence?

A nurse is caring for a client who is 3 hr postoperative following abdominal surgery.Which of the following assessment data should the nurse report to the provider?

A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?