When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

Problem identified during assessment

Interventions planned for the patient

Patient's subjective complaints

Evaluation of care provided

Answer and Explanation

The Correct Answer is A

A. Problem identified during assessment. This is correct because in the PIE documentation format, "P" stands for "Problem," which refers to the nursing diagnosis or issue identified based on assessment findings. This section describes the primary concern that requires intervention.

B. Interventions planned for the patient. This is incorrect because interventions are documented under the "I" (Intervention) section of the PIE format, which outlines the nursing actions taken to address the identified problem.

C. Patient’s subjective complaints. This is incorrect because subjective complaints contribute to the assessment but do not represent the complete "Problem" component of the PIE format. The problem should be stated as a nursing diagnosis or issue based on assessment data.

D. Evaluation of care provided. This is incorrect because evaluation belongs under the "E" (Evaluation) section of the PIE format, which describes the patient's response to the interventions provided.

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Correct Answer is D

Explanation

A. This patient is newly admitted and potentially unstable, requiring nursing assessment before delegation.

B. Active bleeding indicates a complication requiring nursing intervention, making this patient inappropriate for delegation.

C. A patient with pneumonia on oxygen requires close monitoring of their respiratory status, which falls under nursing responsibilities.

D. This patient is stable and only needs assistance, making them appropriate for NAP delegation.

A. Patient will be offered laxatives or stool softeners this shift. B. Patient will have one soft, formed bowel movement by end of shift. C. Patient will not take any pain medications this shift. D. Patient will walk unassisted to bathroom by the end of shift. E. Answer: B

Correct Answer is B

Explanation

A. Patient will be offered laxatives or stool softeners this shift. This is incorrect because offering a medication is an intervention rather than an outcome. Outcomes should focus on the patient’s response to nursing care.

B. Patient will have one soft, formed bowel movement by the end of shift. This is correct because it is a specific, measurable, achievable, realistic, and time-bound (SMART) goal. The outcome directly addresses the problem of constipation and provides a clear indicator of improvement.

C. Patient will not take any pain medications this shift. This is incorrect because withholding pain medication is not an appropriate strategy for managing constipation. Instead, interventions such as increasing fiber, fluids, activity, or stool softeners should be considered.

D. Patient will walk unassisted to the bathroom by the end of the shift. This is incorrect because, although mobility can help improve bowel function, it does not directly measure the resolution of constipation. The outcome should focus on bowel movement frequency and consistency.

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When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

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Naxlex Comprehensive Predictor Exams

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