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.

PIE charting.

Focus charting.

Narrative charting.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Log off the system when leaving the workstation.

This is a correct action to ensure confidentiality and security of electronic health records (EHRs).

Logging off prevents unauthorized access to client information by other users who may use the same workstation.It also protects the system from malware or cyberattacks that may compromise the data integrity or availability.

B. Shred any printouts before discarding them.

This is also a correct action to ensure confidentiality and security of EHRs.

Shredding any printouts that contain client information prevents them from being accessed by unauthorized persons who may find them in the trash or recycling bins.It also complies with the legal and ethical obligations to protect the privacy of clients.

C. Use a personal digital assistant (PDA) to access client information.

This is an incorrect action to ensure confidentiality and security of EHRs.

Using a PDA to access client information may expose the data to unauthorized access, loss, theft, or damage.

PDAs are typically not encrypted or password-protected, and may not have adequate security features or software updates to prevent cyberattacks or malware infections.PDAs may also not be compatible with the EHR system or follow the data standards and interoperability requirements.

D. Change the password at regular intervals.

This is another correct action to ensure confidentiality and security of EHRs.

Changing the password at regular intervals reduces the risk of password cracking, guessing, or phishing by unauthorized users or hackers.It also helps to maintain the accountability and authentication of authorized users who access the EHR system.

E. Report any breaches or attempted breaches to the appropriate authority.

This is also a correct action to ensure confidentiality and security of EHRs.

Reporting any breaches or attempted breaches to the appropriate authority helps to identify and mitigate the impact of any data loss, corruption, or disclosure.It also helps to comply with the legal and regulatory obligations to notify the affected clients and stakeholders, and to prevent further breaches or incidents.

A. SOAP charting. B. PIE charting. C. Focus charting. D. Narrative charting.

Correct Answer is D

Explanation

Narrative charting.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using a computerized documentation system in a health care facility. Which of the following actions should the nurse take to ensure confidentiality and security? (Select all that apply.).

Correct Answer is ["A","B","D","E"]

Explanation

Correct Answer is D

Explanation

A nurse is using focus charting to document a client’s progress notes. What are the advantages of using focus charting? (Select all that apply.).

A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia. The nurse should follow which of the following guidelines when using an EHR system ? (Select all that apply.).

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

A nurse is preparing to report a change in a client’s condition to another health care provider. What should the nurse include in the report?

A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

A nurse is reviewing the record system used in an agency. Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals? (Select all that apply.).

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).