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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D.

Choice A rationale:

Assisting the client to a side-lying position is not necessary when administering nasal decongestant drops. The client can be in an upright position or slightly tilted back.

Choice B rationale:

Holding the dropper 2 cm (1 in) above the naris is not a standard guideline for administering nasal decongestant drops. The dropper should be inserted into the nostril without touching the inside of the nostril to avoid contamination.

Choice C rationale:

Instructing the client to stay in the same position for 2 min is not necessary. After the administration of the nasal decongestant drops, the client can resume their normal activities.

Choice D rationale:

Telling the client to blow her nose gently before the instillation is the correct action. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.

A. Assessment. B. Planning. C. Evaluation. D. Implementation.

Correct Answer is B

Explanation

Choice A rationale:

Assessment Assessment is the first step of the nursing process, where the nurse collects data about the patient's condition. While this step is crucial for understanding the patient's needs, it does not involve formulating goals for a positive outcome. Therefore, it is not the correct choice in this context.

Choice B rationale:

Planning Planning is the step of the nursing process where the nurse formulates goals and develops a care plan to achieve those goals. This includes setting objectives for the patient's care and determining the best course of action. In this case, the nurse is formulating goals for a positive outcome, making choice B the correct answer.

Choice C rationale:

Evaluation Evaluation is the step where the nurse assesses the patient's response to the care provided and determines whether the goals have been met. While important, it does not involve the initial formulation of goals, so it is not the correct choice for this question.

Choice D rationale:

Implementation Implementation involves carrying out the plan of care, putting the planned interventions into action. It doesn't focus on goal formulation, so it is not the correct answer in this context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is admitting a new client.Which of the following steps of the nursing process is the nurse performing when formulating goals for a positive outcome?

Correct Answer is B

Explanation

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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?