The nurse is caring for a client and the following sequence of events occur:. 1428: BP: 88/36 mm Hg. 1430: Dr. Jones paged.
1445: No return call from Dr. Jones.
1450: BP 90/40 mm Hg. 1455: Dr. Jones paged and charge nurse notified.
1505: No return call from Dr. Jones.
What should the nurse document in the patient's chart regarding the sequence of events described above?
Dr. Jones paged at 1430 and 1455 about low blood pressure readings.
No return call from Dr. Jones.
Patient and family informed that Dr. Jones may not call back.
Dr. Jones paged at 1430 of patient's BP 88/36 mm Hg. Repeat BP at 1450 90/40 mm Hg. Dr. Jones paged at 1455.
No orders received.
The Correct Answer is B
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Correct Answer is A
Explanation
Choice A rationale:
In the SOAP format used for medical documentation, "P" stands for Plan. The "P" portion of the note includes the healthcare provider's plan for the patient, which may involve treatments, medications, or other interventions. Option A discusses the patient's ability to walk unassisted, feelings of safety while ambulating, and plans for discharge home in 3 days. This information represents the provider's plan for the patient's care and fits the "P" portion of the SOAP note.
Choice B rationale:
Option B describes the patient's physical examination findings related to range of motion and reflexes in the lower extremities. This information falls under the "Objective" section of the SOAP note, which includes observable and measurable data. While important for the overall patient assessment, it does not represent the provider's plan for the patient's care (the "P" portion of SOAP).
Correct Answer is B
Explanation
Choice A rationale:
Placing the pulse oximeter probe on a finger with slow or delayed capillary refill can lead to inaccurate readings. Slow capillary refill indicates poor peripheral perfusion, which may affect the accuracy of pulse oximetry readings. The nurse should select a finger with normal capillary refill to obtain accurate readings.
Choice B rationale:
Documenting the pulse oximeter reading as a percent is the correct action. Pulse oximeter readings are expressed as percentages, representing the oxygen saturation level in the patient's blood. Normal oxygen saturation levels typically range from 95% to 100%. Documenting the reading in percent allows healthcare providers to monitor the patient's oxygenation status accurately.
Choice C rationale:
Assuring that the reading is taken in bright light, such as sunlight or fluorescent light, is incorrect. Bright light can interfere with the accuracy of pulse oximetry readings by causing the sensor to misinterpret external light as a pulsatile signal. To obtain accurate readings, the pulse oximeter should be used in a well-lit environment but away from direct bright light sources.
Choice D rationale:
Avoiding the removal of dark nail polish before obtaining the reading is incorrect. Dark nail polish can interfere with the pulse oximeter's ability to detect the pulsatile signal from the patient's finger, leading to inaccurate oxygen saturation readings. The nurse should advise the patient to remove dark nail polish or choose another finger without nail polish for the measurement.
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