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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

The nurse should use the following abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min:.

• O2: This stands for oxygen and indicates the type of gas being delivered to the patient.

• NC: This stands for nasal cannula and indicates the device used to deliver oxygen to the patient.

• SpO2: This stands for peripheral oxygen saturation and indicates the percentage of hemoglobin that is saturated with oxygen in the blood.

It is measured by a pulse oximeter attached to the patient’s finger or earlobe.

• RR: This stands for respiratory rate and indicates the number of breaths per minute that the patient takes.

It is an important vital sign to monitor in patients with respiratory conditions.

Choice C is wrong because LPM is not an accepted abbreviation for oxygen therapy.LPM stands for liters per minute and indicates the flow rate of oxygen being delivered to the patient.However, it should not be abbreviated as LPM, but written out in full or as L/min.This is to avoid confusion with other abbreviations such as lpm (lowercase L) which stands for light per minute, a unit of luminous flux.

Normal ranges for SpO2 and RR vary depending on the age, health status and activity level of the patient, but generally they are:.

• SpO2: 95% to 100% for healthy adults.

Lower values may indicate hypoxemia (low blood oxygen level) or other conditions affecting oxygen delivery or uptake in the body.

• RR: 12 to 20 breaths per minute for healthy adults.

Higher or lower values may indicate respiratory distress, infection, pain, anxiety or other conditions affecting breathing.

A. The client’s vital signs, oxygen saturation, and respiratory status. B. The client’s medical history, allergies, and current medications. C. The client’s nursing diagnosis, goals, and expected outcomes. D. The client’s family contacts, insurance information, and advance directives.

Correct Answer is A

Explanation

The client’s vital signs, oxygen saturation, and respiratory status.

This is because the admission nursing assessment is a comprehensive evaluation of the client’s physical, mental, emotional, and social status, as well as their current health problems and needs.

The admission assessment provides baseline data for comparison and planning of care.The client’s vital signs, oxygen saturation, and respiratory status are essential components of the admission assessment for a client who has pneumonia, as they reflect the severity of the infection and the risk of complications.

Choice B is wrong because the client’s medical history, allergies, and current medications are part of the health history interview, which is a component of the admission assessment but not the entire documentation.Choice C is wrong because the client’s nursing diagnosis, goals, and expected outcomes are part of the planning and implementation phases of the nursing process, which come after the assessment phase.Choice D is wrong because the client’s family contacts, insurance information, and advance directives are part of the administrative data collection, which is not directly related to the client’s health status or nursing care.

Normal ranges for vital signs vary depending on age, gender, and health conditions, but generally they are as follows:.

• 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: less than 120/80 mm Hg.

• Oxygen saturation: 95% to 100%.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.).

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

Explanation

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?

Correct Answer is A

Explanation

A nurse is using CBE documentation for a client who has diabetes mellitus. The nurse administers insulin to the client and documents this on a:.

A nurse is using the focus charting method to document care for a client who has diabetes mellitus. Which of the following terms should the nurse use to begin each entry?

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 working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

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 documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

What is one advantage of using a computerized system for documentation and reporting?