A nurse is caring for a client.

• Medication Administration Record:

  • Budesonide 6 mg PO daily.

• Laboratory Results:

  • Hematocrit (Hct): 47% (Normal range: 37% to 52%)
  • Hemoglobin (Hgb): 16 g/dL (Normal range: 12 to 18 g/dL)
  • Potassium: 3.6 mEq/L (Normal range: 3.5 to 5.0 mEq/L)

• History and Physical:

  • BMI: 16 (Reference Range:18.5 - 24.9)
  • History of type 2 diabetes mellitus.
  • Nonsmoker.
  • New diagnosis of Crohn's disease.

Click to highlight the findings that increase the client's susceptibility to infection.

To deselect a finding, click on the finding again.

Choice A rationale:

Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.

Choice B rationale:

Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.

Choice C rationale:

Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.

Choice D rationale:

SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.

The correct answer is Choice A.

Choice A rationale: Using a cell phone to request assistance from the client's room ensures timely communication and enhances patient care. Quick access to help can be vital in emergency situations, ensuring prompt and effective intervention.

Choice B rationale: Sending a personal text to a co-worker during work hours is unprofessional and can lead to distractions. It can compromise patient care and violates workplace policies on personal device usage, ensuring focus remains on patient safety and care.

Choice C rationale: Calling the client's family member per their request can violate privacy and confidentiality regulations, such as HIPAA in the US. Communication with family should go through proper channels to ensure compliance with legal and ethical standards.

Choice D rationale: Taking a photo of a client's incision site for learning purposes without proper consent and documentation breaches patient confidentiality and privacy. It could also result in legal ramifications and violates institutional policies on using personal devices for work-related tasks.