Observed facial grimace and guarding of the abdomen.

This is an example of a data entry in the DAR format because it describes the objective and subjective information that the nurse collected from the client.Data entries can include vital signs, physical assessment findings, laboratory results, and client statements.

Choice A is wrong because it is an example of an action entry in the DAR format.Action entries describe the nursing interventions that the nurse performed to address the client’s problem or need.

For example, administering medication, providing education, or applying a dressing.

Choice B is wrong because it is an example of a response entry in the DAR format.Response entries describe the client’s reaction or outcome to the nursing interventions.

For example, reporting pain relief, expressing satisfaction, or showing improvement.

Choice D is wrong because it is also an example of an action entry in the DAR format.

It describes another nursing intervention that the nurse performed to help the client cope with pain.

The DAR format is a type of focus charting that helps nurses document problems identified in the client care plan.

It stands for data, action, and response.Some nurses may use the F-DAR format, which adds a focus component to provide a clearer context and prioritization of the client’s needs.The focus can be a nursing diagnosis, a change in condition, a symptom, or an event.

These are appropriate components of the plan in the SOAP format.SOAP stands forSubjective, Objective, Assessment, Planand it is a form of written documentation many healthcare professions use to record a patient or client interaction.

• Ais correct because monitoring blood pressure and pulse every 4 hours is an objective and measurable intervention that can help evaluate the patient’s condition and response to treatment.

• Bis correct because educating the client about dietary sodium restriction is an intervention that can help prevent or reduce hypertension and its complications.

• Dis correct because evaluating the effectiveness of antihypertensive medication is an intervention that can help assess the patient’s progress and adjust the treatment plan accordingly.

• Cis wrong because assessing for signs of orthostatic hypotension is not an intervention, but an observation that belongs to the objective section of the SOAP note.

• Eis wrong because identifying the risk factors for developing hypertension is not an intervention, but an assessment that belongs to the assessment section of the SOAP note.

Normal ranges for blood pressure are<120/80 mmHgfor normal,120-129/<80 mmHgfor elevated,130-139/80-89 mmHgfor stage 1 hypertension, and≥140/≥90 mmHgfor stage 2 hypertension.Normal ranges for pulse rate are60-100 beats per minutefor adults.

Instructed the client on how to use a glucometer at home.

This is an example of an intervention entry in the SOAPIER format, which stands for subjective, objective, assessment, plan, intervention, and evaluation.An intervention entry describes any actions that were taken to support the patient based on the assessment and plan.

In this case, the nurse provided patient education on how to monitor blood glucose levels at home using a glucometer.

Choice A is wrong because it is an example of a subjective entry, which includes anything related to what the patient has told the nurse.This should be recorded exactly as the patient reports and in quotation marks.

Choice B is wrong because it is an example of an objective entry, which consists of any measurable observations that the nurse makes during the patient assessment.This includes vital signs, laboratory results, physical findings, and other data that can be verified.

Choice D is wrong because it is an example of an assessment entry, which is the nurse’s interpretation of the subjective and objective information and conclusions regarding the patient’s condition.This may include nursing diagnoses, problem statements, or clinical impressions.

Choice E is wrong because it is an example of an evaluation entry, which describes the result of any interventions and whether they achieved the desired outcomes.This may include patient feedback, changes in condition, or need for further action.

Normal ranges for blood glucose levels vary depending on the type of test and the time of day.Generally, a normal fasting blood glucose level is between 70 and 100 mg/dL, while a normal postprandial (after meal) blood glucose level is less than 140 mg/dL.A blood glucose level of 250 mg/dL before lunch indicates hyperglycemia (high blood sugar), which is a common complication of diabetes mellitus.

“I feel more calm and relaxed after practicing the breathing exercises.”

This is an example of an evaluation entry in the focus charting method because it describes the client’s response to the nursing intervention of teaching relaxation techniques.Evaluation entries reflect theevaluation phaseof the nursing process and show whether the client’s goals and outcomes have been met or not.

Choice A is wrong because it is an example of an action entry, not an evaluation entry.Action entries reflect theplanning and implementation phaseof the nursing process and include immediate and future nursing actions.

Choice B is wrong because it is an example of a data entry, not an evaluation entry.Data entries reflect theassessment phaseof the nursing process and include subjective and objective information about the client’s health status.

Choice C is wrong because it is an example of a focus, not an evaluation entry.A focus is a key word or phrase that identifies the client’s concern, problem, or strength.It can be derived from a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a standard of care.

Choice E is wrong because it is an example of an action entry, not an evaluation entry.Action entries reflect theplanning and implementation phaseof the nursing process and include immediate and future nursing actions.

Focus charting is a method for organizing health information in the client’s record using nursing terminology to describe the client’s health status and nursing actions.

It uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response (DAR).

Normal ranges for vital signs are:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg (systolic/diastolic).

The client’s oxygen saturation level has improved from 88% to 95% after receiving oxygen therapy for 24 hours.

This is an example of an evaluation entry in the PIE documentation system because it describes the outcome of the intervention (oxygen therapy) for the problem (low oxygen saturation level) using objective data (percentage).

Other choices are wrong because:.

• Choice A: The client has been coughing less frequently and reports feeling less short of breath.

This is an example of an intervention entry because it describes the actions taken by the nurse to address the problem (coughing and shortness of breath).

• Choice B: The client has a productive cough with yellowish sputum and crackles in the lower lobes of both lungs.

This is an example of a problem entry because it identifies the signs and symptoms of the health condition (pneumonia).

• Choice D: The client will maintain a normal oxygen saturation level of at least 92% with supplemental oxygen as needed.

This is an example of a plan entry because it states the expected outcome or goal for the problem (low oxygen saturation level).

The PIE documentation system is a process-oriented system that uses the acronym PIE to document theProblem,Intervention, andEvaluation of the patient’s progress.It integrates care planning with progress notes and does not separate the patient from the environmental influences.The normal oxygen saturation level for healthy adults is between 95% and 100%.