It keeps data from each person or department in a separate section.A source-oriented record is a type of documentation system that organizes the data according to the source of information, such as the physician, nurse, laboratory, or physical therapy.This format has the advantage of making it easy to locate and trace the information from each person or department who provided care to the client.

Choice A is wrong because it does not encourage collaboration among health care providers.In fact, a source-oriented record may hinder communication and coordination of care because the data are fragmented and scattered throughout the chart.

Choice B is wrong because it does not organize the data according to the client’s problems.A problem-oriented medical record (POMR) is a different type of documentation system that arranges the data based on the problems identified by the health care team.The POMR has four components: database, problem list, plan of care, and progress notes.

Choice C is wrong because it does not track the status of each problem using a problem list.This is also a feature of the POMR, not the source-oriented record.A problem list is a numbered list of the client’s current and resolved problems that serves as an index to the progress notes.

The nurse shouldnumber the care plan to correspond to the problem listandupdate the problem list as needed.These actions are consistent with the principles of the problem-oriented medical record (POMR), which is a method of organizing patient information by the health problems that require attention.The POMR includes a patient database, a problem list, a plan of care, and progress notes.

Choice A is wrong because the nurse should not generate the care plan from the database, but rather from the problem list.The problem list is the centerpiece of the POMR and reflects the patient’s current health status and needs.

Choice C is wrong because the nurse should not repeat assessments and interventions that apply to more than one problem, but rather use cross-referencing to avoid duplication and confusion.

Choice E is wrong because the nurse should not use a standardized format for chart entries, but rather use a SOAP format (subjective, objective, assessment, plan) or a modified version of it (such as SOAPIE or SOAPIER) to document each problem and its progress.

The normal ranges for some common laboratory tests are:.

• CBC (complete blood count):.

➤ Hemoglobin: 13.5-17.5 g/dL (male), 12-16 g/dL (female).

➤ Hematocrit: 38.8-50% (male), 34.9-44.5% (female).

➤ White blood cell count: 4.5-11 x 10^9/L.

➤ Platelet count: 150-450 x 10^9/L.

• SMAC (sequential multiple analysis computer):.

➤ Sodium: 135-145 mEq/L.

➤ Potassium: 3.5-5 mEq/L.

➤ Chloride: 98-106 mEq/L.

➤ Bicarbonate: 22-29 mEq/L.

➤ Blood urea nitrogen: 7-20 mg/dL.

➤ Creatinine: 0.6-1.2 mg/dL (male), 0.5-1.1 mg/dL (female).

➤ Glucose: 70-110 mg/dL.

➤ Calcium: 8.5-10.2 mg/dL.

• EKG (electrocardiogram):.

➤ Heart rate: 60-100 beats per minute.

“The client reports feeling less pain in his left leg.”

This is the subjective data because it is based on the client’s own perception and feelings.Subjective data is what the client tells the nurse or what the nurse observes from the client’s behavior.

Choice A is wrong because it is objective data, which is measurable and observable by the nurse or other healthcare providers.Objective data is what the nurse sees, hears, feels, or smells.

Choice C is wrong because it is also objective data, as it can be measured by the nurse using a goniometer or other tools.

Choice D is wrong because it is also objective data, as it can be observed by the nurse or documented in the care plan.

Normal ranges for vital signs are as follows:.

• Blood pressure: 90/60 mmHg to 120/80 mmHg.

• Pulse rate: 60 to 100 beats per minute.

• Respiratory rate: 12 to 20 breaths per minute.

• SpO2: 95% to 100%.

• Temperature: 36.5°C to 37.5°C.

“Administered bisacodyl suppository as prescribed.”.

The PIE format is a method of documentation that states theproblemor diagnosis (P), theinterventionor action the nurse takes (I), and theevaluationof the results (E).It eliminates the need for a traditional care plan by incorporating it into the progress notes.

The intervention is the action that the nurse takes to address the problem.

In this case, the problem is constipation, and the intervention is administering a bisacodyl suppository as prescribed by the physician.

This is a specific and measurable action that can be evaluated later.

Choice A is wrong because it is not an intervention, but a health promotion activity.

Encouraging the client to increase fluid and fiber intake is a good practice, but it is not directly related to the problem of constipation.

Choice B is wrong because it is not an intervention, but an assessment.

Assessing the client’s bowel sounds and abdominal distension is part of the data collection process, but it does not solve the problem of constipation.

Choice D is wrong because it is not an intervention, but an evaluation.

Evaluating the client’s response to the suppository is the last step of the PIE format, where the nurse determines if the intervention was effective or not.

It does not describe what the nurse did to address the problem of constipation.

The normal range for bowel movements varies from person to person, but generally, having less than three bowel movements per week is considered constipation.Constipation can be caused by various factors, such as medication side effects, dehydration, low-fiber diet, lack of physical activity, or underlying medical conditions.

“Instructed the client on low-sodium diet and exercise.”

This is the action that the nurse took to address the client’s problem of hypertension.

The action should describe the nursing intervention that was performed to help the client achieve the expected outcome.

Choice A is wrong because it is not an action, but a data.

Data is the information that the nurse collected about the client’s condition, such as vital signs, symptoms, or test results.

Data should be factual and objective.

Choice C is wrong because it is not an action, but a response.

Response is the outcome or result of the nursing intervention, such as the client’s reaction, behavior, or change in condition.

Response should be measurable and evaluative.

Choice D is wrong because it is not an action, but a focus.

Focus is the reason or purpose for writing the note, such as a nursing diagnosis, a change in condition, or a patient education need.

Focus should be concise and specific.

DAR format is a method of nursing documentation that stands for Data, Action, and Response.It is a form of focus charting that records significant events or changes in the client’s condition that require nursing care.DAR notes are organized, concise, and informative, and they help to communicate the nursing process and plan of care among health care providers.