A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?
Client is asleep and resting
Client had 150 mL of emesis in last hour
Ondansetron 4 mg IV bolus for nausea and vomiting
Client reports nausea and vomiting 30 minutes following surgery
The Correct Answer is C
A. This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B. This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C. It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D. This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using hot water is not recommended as it can cause skin irritation or burns, especially in vulnerable populations such as those with urinary incontinence. Warm or lukewarm water is more appropriate for cleaning sensitive skin.
B. Applying cornstarch can sometimes be used to absorb moisture and reduce friction; however, it is not the first-line recommendation. It may also promote yeast growth in the presence of moisture, so it should be used with caution.
C. Using a pH-balanced cleanser helps maintain the natural acidity of the skin, which is important for skin integrity and preventing irritation. This type of cleanser is less likely to disrupt the skin's barrier, reducing the risk of skin breakdown and infection.
D. While air-drying can be beneficial in some cases, it is generally not the best practice after cleaning. Gently patting the skin dry with a soft towel is usually recommended to avoid irritation. Allowing skin to remain damp can increase the risk of skin breakdown.
Correct Answer is C
Explanation
A. As individuals age, balance often decreases due to factors such as changes in vision, muscle strength, and proprioception. Older adults may be more prone to falls because of diminished balance and coordination.
B. While bones may become denser in some cases due to increased calcification, this is not the typical expectation. Generally, older adults experience a decrease in bone density, which can lead to conditions such as osteoporosis. Aging bones may lose calcium and other minerals, making them more fragile.
C. Age-related changes in joints, such as decreased synovial fluid production, cartilage degeneration, and changes in ligaments, can lead to increased stiffness and discomfort in joints. Conditions like osteoarthritis can also contribute to this stiffness.
D. With aging, there is usually a decrease in muscle mass and strength, known as sarcopenia. Older adults may experience a gradual loss of muscle tissue, leading to decreased overall muscle mass and strength.
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