A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility.

Which of the following data should the nurse record on this type of document?

Daily weight, blood pressure, and pulse

Medication administration record.

Nursing diagnosis and care plan.

Discharge planning and referral summary.

Answer and Explanation

The Correct Answer is A

Daily weight, blood pressure, and pulse.

A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc. A flow sheet is useful for clinical communication and tracking the patient’s condition over time. A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time. A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them. A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.

These documents are not part of a flow sheet.

Choice B is wrong because a MAR is not a flow sheet.

Choice C is wrong because a nursing diagnosis and care plan is not a flow sheet.

Choice D is wrong because a discharge planning and referral summary is not a flow sheet.

Normal ranges for daily weight vary depending on the patient’s age, height, gender, and medical condition. However, a general guideline is that a weight gain or loss of more than 2 kg (4.4 lbs) in a week or 0.9 kg (2 lbs) in a day may indicate fluid retention or dehydration. Normal ranges for blood pressure are less than 120/80 mmHg for adults, and less than 95/65 mmHg for children. Normal ranges for pulse are 60 to 100 beats per minute for adults, and 70 to 120 beats per minute for children.

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Correct Answer is ["A","B","C","E"]

Explanation

A flow sheet is a type of document that recordsroutineandfrequentdata in agraphicalortabularform.It is used tomonitorandevaluatethe patient’s condition and response to treatment over time.A flow sheet should include information that isrelevant,conciseandeasy to read.

• Choice A is correct because vital signs are one of the most common and important data that need to be recorded and monitored regularly for any patient.

• Choice B is correct because allergies are essential information that can affect the patient’s treatment plan and prevent adverse reactions.

• Choice C is correct because medication administration is another crucial data that shows what drugs, doses, routes and times the patient has received or will receive.

• Choice D is wrong because medical history is not a routine or frequent data that needs to be recorded in a flow sheet.Medical history is usually documented in a separate form that provides more details and background information about the patient’s past and present health conditions.

• Choice E is correct because intake and output are important data that indicate the patient’s fluid balance and renal function.

They need to be recorded and monitored regularly, especially for patients who have fluid restrictions.

A. Subjective, Objective, Assessment, Plan. B. Situation, Observation, Action, Problem. C. Summary, Outcome, Analysis, Process. D. Source, Opinion, Accuracy, Purpose.

Correct Answer is A

Explanation

Subjective, Objective, Assessment, Plan.This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.

Choice B is wrong becauseSituation, Observation, Action, Problemis not a documentation method, but a communication tool used in handovers and briefings.

Choice C is wrong becauseSummary, Outcome, Analysis, Processis not a documentation method, but a framework for writing reflective essays.

Choice D is wrong becauseSource, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.

SOAP format helps to organize the information collected from the patient in a clear and consistent manner.

It consists of four components:.

• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.

• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.

• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.

• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.

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A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility. Which of the following data should the nurse record on this type of document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is using SOAP format to document a client’s progress note. What does SOAP stand for?

Correct Answer is A

Explanation

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