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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Correct Answer is C

Explanation

Choice A rationale:

Material safety data sheets (MSDS) primarily contain information related to hazardous chemicals and substances used in healthcare settings. While MSDS can be valuable for safety purposes, they do not provide comprehensive information on specimen collection protocols. Therefore, MSDS is not the most appropriate source for revising the specimen collection protocol.

Choice B rationale:

Client medical records are essential for individual patient care and documentation. However, they do not contain the information needed to revise the protocol for specimen collection on the unit. Medical records are specific to individual patient histories, diagnoses, and treatments, and do not address broader unit-wide protocols.

Choice C rationale:

Facility policy and procedures are the most appropriate source for retrieving information to revise the protocol for specimen collection on the unit. These policies and procedures are specifically designed to guide healthcare providers in delivering safe and effective care within the facility. They encompass standardized protocols for various clinical procedures, including specimen collection, making them the ideal source for the nurse's research.

Choice D rationale:

Evidence-based practice (EBP) involves using the best available research evidence, clinical expertise, and patient values to guide healthcare decisions. While EBP is crucial in healthcare, it is not the primary source for revising unit-specific protocols. EBP provides a broader framework for making clinical decisions but may not cover the specific policies and procedures unique to the facility.

A. "There are 4 rights of delegation.”. B. "It is the duty of the delegatee to perform a task without asking questions when it is delegated.”. C. "The nurse manager is responsible for delegating nursing tasks during each shift.”. D. "I am responsible for ensuring that a delegated task is completed.”.

Correct Answer is D

Explanation

Choice A rationale:

There are actually five rights of delegation: right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. This statement is not accurate.

Choice B rationale:

It is not the duty of the delegatee to perform a task without asking questions. Effective delegation involves clear communication, including the opportunity for the delegatee to ask questions and seek clarification as needed.

Choice C rationale:

While the nurse manager plays a role in delegation, the responsibility for delegation does not solely rest on the nurse manager. Delegation is a shared responsibility among all nurses, and the person delegating the task must ensure it is appropriate and clear.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

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?