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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Related Questions
Correct Answer is B
Explanation
A. Warm water is appropriate for washing the feet, but it's important to avoid very hot water, which can damage the skin.
B. This is the best way to prevent moisture buildup between the toes, which can lead to fungal infections. Air drying helps to keep the skin dry and reduces the risk of infection.
C. Soaking the feet can soften the skin and make it easier to remove dead skin cells, but it's important to avoid prolonged soaking, as this can dry out the skin and increase the risk of infection.
D. Applying moisturizer between the toes can trap moisture and create a breeding ground for bacteria and fungi. It's best to apply moisturizer to the top and bottom of the feet, avoiding the areas between the toes.
Correct Answer is C
Explanation
A. This action is important for maintaining balance during the move, but it should be done after establishing a strong base of support.
B. Engaging core muscles can help protect the nurse's back during lifting and moving, but it's not the first step in the process.
C. This provides a strong base of support, which is crucial for safe and efficient patient repositioning.
D. While raising the bed can help reduce the nurse's bending and straining, it's not the initial step. Proper body mechanics should be prioritized first.
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