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 D
Explanation
Choice A rationale
This is a direct quote from the client, providing subjective data about their difficulty with the syringe markings. Documenting client statements verbatim, enclosed in quotation marks, offers valuable insight into their perspective and experiences.
Choice B rationale
This is an objective finding, reporting a specific laboratory value (Fasting Blood Sugar). Documenting numerical data with units of measurement is essential for tracking trends and assessing the client's condition. The normal range for FBS is typically 70-100 mg/dL.
Choice C rationale
This documents an observed skill and the client's ability to perform a specific task correctly. Documenting observed behaviors and skills demonstrates the client's learning and competence in self-care activities.
Choice D rationale
The phrase "seems to be more comfortable" is a subjective interpretation by the nurse rather than an objective observation or a direct client statement. Documentation should primarily focus on factual observations, client statements, and measurable data rather than the nurse's personal opinions or assumptions.
Correct Answer is D
Explanation
Choice A rationale
Lack of exercise primarily affects the cardiovascular and musculoskeletal systems and is not a direct cause of fluid volume deficit. While it can indirectly impact overall health, it doesn't typically lead to significant fluid loss.
Choice B rationale
Excessive food intake, especially if high in sodium, can actually lead to fluid volume excess rather than deficit due to osmotic shifts and water retention.
Choice C rationale
Bed rest can lead to some fluid redistribution within the body but does not directly cause a significant loss of total body fluid. Immobility can affect other physiological processes more directly.
Choice D rationale
Excessive gastrointestinal losses, such as vomiting, diarrhea, or drainage from nasogastric tubes or ostomies, directly remove significant amounts of fluid and electrolytes from the body, leading to fluid volume deficit.
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