A nurse is completing a SOAP note in a client's chart. In which of the following sections should the client's vital signs be documented?
Objective
Plan
Action
Subjective
The Correct Answer is A
A. Vital signs should be documented in the Objective section of the SOAP note because they are measurable, observable data.
B. The Plan section outlines the actions and treatments planned based on the assessment data.
C. The Action section details the specific interventions carried out during the client's care.
D. The Subjective section includes the client's perceptions, feelings, and statements about their health.
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Related Questions
Correct Answer is B
Explanation
A. Waiting to document medications until the end of a shift increases the risk of errors and delays in patient care due to potential inaccuracies.
B. Avoiding distractions during medication preparation helps maintain focus and reduces the likelihood of errors.
C. Preparing medications for multiple clients simultaneously increases the risk of medication mix-ups and errors.
D. Medications should not be removed from automatic dispensing systems before review by pharmacists, as this can lead to medication errors and compromised safety protocols.
Correct Answer is D
Explanation
A. Fowler's position is a semi-sitting position typically used for respiratory or cardiac conditions, not for rectal suppository administration.
B. Dorsal recumbent position is lying on the back with knees flexed, which is used for genital exams or urinary catheterization, not for rectal suppository administration.
C. Prone position is lying face down, which is not suitable for rectal suppository administration.
D. Sim's position, lying on the left side with the right knee flexed, facilitates rectal suppository insertion and retention.
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