Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is caring for a client who has just undergone surgery for appendicitis.
The nurse documents in the client’s chart : “Client resting comfortably in bed with IV fluids infusing at 125 mL/hr.
Dressing clean , dry , and intact.
No complaints of pain or nausea.
Denies any problems or concerns.” This type of documentation is an example of :.
SOAP charting is a type of documentation that is organized by four categories: Subjective, Objective, Assessment, and Plan.
It is commonly used in problem-oriented medical records.
PIE charting is a type of documentation that uses three categories: Problem, Intervention, and Evaluation.
It is based on the nursing process and eliminates the need for a separate care plan.
Focus charting is a type of documentation that uses three categories: Data, Action, and Response.
It emphasizes the patient’s concerns, problems, or strengths rather than medical diagnoses.
Narrative charting. This type of documentation is an example of narrative charting because it chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift in a descriptive format.
Narrative charting.
This type of documentation is an example of narrative charting because it chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift in a descriptive format.
Some other choices are:.
• Choice A is wrong because SOAP charting is a type of documentation that is organized by four categories: Subjective, Objective, Assessment, and Plan.
It is commonly used in problem-oriented medical records.
• Choice B is wrong because PIE charting is a type of documentation that uses three categories: Problem, Intervention, and Evaluation.
It is based on the nursing process and eliminates the need for a separate care plan.
• Choice C is wrong because Focus charting is a type of documentation that uses three categories: Data, Action, and Response.
It emphasizes the patient’s concerns, problems, or strengths rather than medical diagnoses.
Normal ranges for vital signs and laboratory values may vary depending on the facility and the patient’s condition.
However, some general ranges 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 or lower.
• Oxygen saturation: 95% or higher.
• Hemoglobin: 12 to 18 g/dL for men, 11 to 16 g/dL for women.
• Hematocrit: 37% to 49% for men, 36% to 46% for women.
• White blood cell count: 4,000 to 11,000 cells/mm3.
• Platelet count: 150,000 to 400,000 cells/mm3.
• Blood glucose: 70 to 110 mg/dL.