A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?
Client is asleep and resting
Client had 150 mL of emesis in last hour
Ondansetron 4 mg IV bolus for nausea and vomiting
Client reports nausea and vomiting 30 minutes following surgery
The Correct Answer is C
A. This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B. This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C. It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D. This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This condition affects the central portion of the retina, causing blurred vision in the center of the visual field.
B. A cataract is a clouding of the lens in the eye that affects vision. This clouding can cause blurred vision, sensitivity to light, and difficulty seeing at night.
C. This is a complication of diabetes that damages the blood vessels in the retina. It can cause blurred vision, floaters, and even blindness.
D. This is a condition that damages the optic nerve. It often causes a gradual loss of peripheral vision.
Correct Answer is C
Explanation
A. Bending at the hips can strain the back muscles. It's better to bend at the knees to lift with the leg muscles.
B. Keeping your feet together reduces stability. It's better to have a wide stance with your feet shoulder- width apart to maintain balance.
C. Standing close to the object reduces the distance the object needs to be lifted and minimizes the strain on the back muscles.
D. Twisting the spine while lifting can cause serious back injuries. It's important to avoid twisting and lift with straight back and legs.
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