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

Answer and Explanation

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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Correct Answer is C

Explanation

A. This component refers to what triggered the pain or any factors that may have contributed to its onset. For example, a nurse might ask if the pain started after eating, exercising, or any other activity. This does not apply to the nurse asking about the quality of the pain.
B. This involves identifying the location of the pain. The nurse would ask the client where the pain is situated (e.g., upper abdomen, lower abdomen, etc.). While important, this is not what the nurse is asking when they inquire about the nature of the pain.
C. This component focuses on describing the nature of the pain itself. The nurse is asking the client to describe what the pain feels like, such as whether it is sharp, dull, throbbing, burning, or cramping. This is the correct choice in this scenario.
D. This refers to how intense the pain is, often measured on a scale (e.g., 0 to 10). The nurse would ask the client to rate their pain intensity. While this is an important aspect of pain assessment, it does not pertain to describing what the pain feels like.

A. Right room B. Right communication C. Right time D. Right documentation

Correct Answer is B

Explanation

A. This is not one of the five rights of delegation. While ensuring that tasks are assigned in the appropriate environment is important, it is not a formal component of delegation principles.
B. This concept is critical in delegation but is not specifically one of the "Five Rights." Effective communication is necessary to ensure that the AP understands the task, its importance, and any specific instructions or expectations.
C. This is not one of the five rights of delegation. However, it does relate to when tasks should be delegated and ensuring that they are completed within a timeframe that is appropriate for patient care. The timing aspect is generally integrated into the context of the task rather than identified as a standalone right.
D. This is also not one of the five rights of delegation. While documentation is essential for maintaining accurate patient records and communication, it does not directly fall under the formal rights of delegation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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