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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Determining the client's goals and expectations regarding hospitalization is crucial for patient-centered care. Understanding what the client hopes to achieve during their stay allows the nurse to tailor the care plan to meet their individual needs and preferences, promoting adherence and satisfaction.
Choice B rationale
Establishing a therapeutic relationship with the client and their wife is fundamental for effective communication and trust. A strong rapport facilitates open dialogue, allowing the nurse to gather accurate information, provide emotional support, and involve the family in the care process.
Choice C rationale
Identifying the client's chief complaints, concerns, and worries is the primary focus of the initial interview. Understanding the main reasons for seeking healthcare helps the nurse to prioritize assessments and interventions, addressing the most pressing issues first.
Choice D rationale
Ascertaining which parts of the interview may require further exploration guides subsequent data collection. Identifying areas where more detailed information is needed ensures a comprehensive understanding of the client's health status and allows the nurse to focus on relevant aspects in follow-up interactions.
Choice E rationale
While reviewing the client's past medical history is important, it is usually a more detailed process that occurs after the initial interview to identify immediate concerns. The initial interview focuses on the present situation and the client's current perspective.
Correct Answer is C
Explanation
Choice A rationale
Signing on with a password authenticates the user and allows them to enter information, but it does not prevent someone with the same password or unauthorized access from altering previously entered data. Passwords control who can access the system, not what they can do once logged in.
Choice B rationale
Charting in privacy ensures confidentiality while the nurse is documenting, preventing unauthorized individuals from viewing the information as it is being entered. However, it does not prevent authorized users from later altering the data.
Choice C rationale
Logging off the electronic documentation system after each entry is crucial for preventing unauthorized access and alterations. Once logged off, the nurse's session is closed, requiring a new login to make any changes, thus ensuring accountability for each entry.
Choice D rationale
Charting in code or using abbreviations can help maintain patient privacy to some extent but does not inherently prevent alteration of the information once it has been entered into the system. Codes can be understood by those with access. \
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