Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.
The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.
These are the only options that describe the subjective and objective data of the patient, which are part of the SOAP documentation method. SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.
These are the only options that describe the subjective and objective data of the patient, which are part of the SOAP documentation method. SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.
Wound culture results are not part of the assessment entry in SOAP documentation. They are part of the investigation results, which are usually documented in the objective section.
Risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment. Nursing diagnoses are usually documented in the plan section of SOAP documentation.
Applied moist heat compresses to the wound site is an intervention, not an assessment. Interventions are also documented in the plan section of SOAP documentation.
These are the only options that describe the subjective and objective data of the patient, which are part of the SOAP documentation method. SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.
Choice C is wrong because wound culture results are not part of the assessment entry in SOAP documentation. They are part of the investigation results, which are usually documented in the objective section.
Choice D is wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment. Nursing diagnoses are usually documented in the plan section of SOAP documentation.
Choice E is wrong because applied moist heat compresses to the wound site is an intervention, not an assessment. Interventions are also documented in the plan section of SOAP documentation.
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.