A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?
Charting by exception (CBE).
Focus charting (DAR).
Problem-oriented medical record (POMR).
SOAP documentation.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: A
Choice A reason: Providing the nurse administering medications with an identifying vest can help reduce medication errors by making it easier for other staff and patients to identify the nurse responsible for medication administration. This can minimize interruptions and distractions, which are common causes of medication errors. It also serves as a visual reminder to the nurse of their critical role in medication safety.
Choice B reason: Removing medications from automatic dispensing systems before they are reviewed by pharmacists is not a recommended practice. Pharmacists play a crucial role in reviewing prescriptions for accuracy and potential drug interactions before dispensing. Therefore, medications should remain in the dispensing system until they have been properly reviewed and approved by a pharmacist.
Choice C reason: Waiting to document medications given to clients until the end of a shift is not advisable. Accurate and timely documentation is essential in healthcare, particularly when it comes to medication administration. Documentation should occur as soon as the medication is given to ensure that all healthcare providers have up-to-date information and to prevent errors such as omissions or duplications.
Choice D reason: Preparing medications for multiple clients at the same time increases the risk of errors, such as mix-ups between patients or incorrect dosing. It is best practice to prepare and administer medications for one client at a time, following the ‘five rights’ of medication administration: the right patient, the right drug, the right dose, the right route, and the right time.
Correct Answer is D
Explanation
The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.
Choice A rationale:
Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).
Choice B rationale:
Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.
Choice C rationale:
Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.
Choice D rationale:
Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.