A nurse is caring for a client who is 3 hr postoperative following abdominal surgery.
Which of the following assessment data should the nurse report to the provider?

Choice A rationale:

In this scenario, the nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). By collecting evidence-based information and research on this topic, the nurse is acting in the role of a researcher. Research in healthcare is essential to stay current with best practices, guidelines, and recommendations, and it helps inform clinical decision-making.

Choice B rationale:

A nurse manager is responsible for overseeing nursing staff, unit operations, and ensuring that the unit operates efficiently and safely. While a nurse manager may use evidence-based information to guide decisions, the primary role described in this scenario is that of a researcher, as the nurse is focused on gathering evidence-based practice on a specific topic.

Choice C rationale:

An educator's primary role is to teach and educate others, such as patients, families, or fellow healthcare professionals. While education often involves the use of evidence-based information, in this scenario, the nurse is primarily focused on gathering evidence rather than directly educating others.

Choice D rationale:

A case manager is responsible for coordinating and managing a patient's care, often involving multiple aspects of healthcare and social services. While case managers may use evidence-based information in their decision-making, the primary role described in this scenario is that of a researcher, as the nurse is focused on gathering evidence-based practice related to CAUTI, not managing a specific patient's case.

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.