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?
Client had 50 ml of emesis in the last hour.
Client reports nausea and vomiting.
Ondansetron 4 mg IM bolus given for nausea and vomiting.
Client is asleep and resting comfortably.
The Correct Answer is C
Choice A rationale
This statement describes an assessment finding, specifically the amount of emesis. In the PIE model, assessment data is typically included in the Problem section to support the identified nursing diagnosis or problem. It provides objective evidence of the client's condition.
Choice B rationale
This statement describes the client's subjective report of symptoms. This information would also fall under the Problem section of the PIE note, as it identifies the issue the nurse is addressing. It represents the client's perception of their condition.
Choice C rationale
This statement details the specific nursing action taken to address the client's problem of nausea and vomiting. The Intervention section of the PIE note clearly outlines the nursing care implemented, including the medication administered, dosage, route, and reason.
Choice D rationale
This statement describes the evaluation of the intervention's effectiveness or the client's current status. In the PIE model, the Evaluation section documents the client's response to the nursing interventions and whether the problem has been resolved, improved, or remains the same.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
While face-to-face hand-off reports are often preferred for direct communication and clarification, they are not always the only acceptable method. Other methods, such as recorded reports or written summaries with opportunities for questions, can also be effective in ensuring continuity of care, especially in situations where face-to-face reporting is not feasible.
Choice B rationale
Providing for the continuity and individualized care of the patient is a primary purpose of hand-off reports. By sharing relevant information about the patient's current condition, care plan, and any recent changes, the hand-off ensures that the receiving nurse has the necessary information to provide consistent and tailored care.
Choice C rationale
Including an opportunity for the receiver to ask questions of the person giving the report is crucial for effective communication and to clarify any ambiguities or obtain additional details. This interactive element helps ensure that the receiving nurse fully understands the patient's situation and can provide safe and appropriate care.
Choice D rationale
Hand-off reports should include up-to-date and recent changes about the patient's condition, treatments, and any new orders or concerns. This ensures that the receiving nurse is aware of the most current information and can adjust care accordingly. Outdated information can lead to errors or omissions in care.
Choice E rationale
Hand-off reports supplement, but do not replace, formal documentation in the patient's medical record. Documentation provides a comprehensive and permanent record of the patient's care, while the hand-off report is a verbal or brief written communication to ensure a smooth transition of care between nurses. Both are essential for effective patient care and communication.
Correct Answer is C
Explanation
Choice A rationale
Subjective opinions like "pleasant to care for" lack specific, objective data about the patient's condition or care provided. Medical documentation should focus on factual observations and interventions related to the patient's health status.
Choice B rationale
"Voiding without difficulty" is a relevant observation regarding the patient's urinary function. However, it lacks specific details such as the amount, color, or clarity of the urine, which are important for a comprehensive assessment.
Choice C rationale
This statement provides specific and objective information about the patient's pain experience. It includes the patient's self-reported pain level (6/10), the location of the pain (left temporal area), and a relevant negative finding (no relief with positioning), all contributing to a clear understanding of the patient's condition.
Choice D rationale
"Onsite looks good" is vague and lacks specific details about the condition of a particular site (e.g., surgical wound, IV insertion site). Effective documentation requires descriptive terms regarding appearance, such as color, presence of drainage, swelling, or redness.
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