A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model.
Which of the following information should be included in the subjective component?
Client reports chest pain after mowing lawn this morning.
Client's blood pressure is 182/98 mm Hg.
Client administered nitroglycerin 0.3 mg SL for chest pain.
Client's skin is pale and diaphoretic.
The Correct Answer is A
Choice A rationale:
In the SOAP charting model, the subjective component is where the client's subjective information and feelings are documented. This includes the client's own reports of symptoms, sensations, and experiences. In this case, the client reporting chest pain after mowing the lawn this morning is a subjective statement made by the client. This information is valuable as it provides insight into the client's perception of their condition and helps healthcare providers understand their symptoms and experiences.
Choice B rationale:
The blood pressure reading (182/98 mm Hg) is an objective measurement, not a subjective statement from the client. Objective data includes measurable and observable information, like vital signs, lab results, and physical examination findings. This type of information is typically documented in the objective component of SOAP charting.
Choice C rationale:
The administration of nitroglycerin (0.3 mg SL) is also an objective action taken by the client, not a subjective statement. It falls under the plan section of the SOAP chart, where healthcare providers outline the actions or interventions taken.
Choice D rationale:
The description of the client's skin (pale and diaphoretic) is also objective data. It represents observable physical signs and is not part of the subjective component, which focuses on the client's own statements and feelings.
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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.
Correct Answer is D
Explanation
Choice A rationale:
Rounding the amount to be administered to the nearest whole number is a step that may be necessary, but it should not be the first action taken. The nurse should first ensure that the dosage calculation is accurate and based on the client's weight in kilograms. Once the dosage in milligrams is calculated, rounding can be considered.
Choice B rationale:
Calculating the dosage in milligrams is an essential step, but it is not the first action the nurse should take. To determine the correct dosage in milligrams, the nurse needs to convert the client's weight from pounds to kilograms first, as the medication order is given in milligrams per kilogram.
Choice C rationale:
Calculating the dosage in milliliters is not the first action to take because the medication is available in milligrams, and the order is based on weight in kilograms. Converting the weight to kilograms is the initial step to ensure that the dose is calculated correctly.
Choice D rationale:
Converting the client's weight to kilograms is the first and most crucial step in this dosage calculation. The medication order is given in milligrams per kilogram, and the client's weight is provided in pounds. To ensure accurate dosing, the nurse must convert the weight to kilograms, as this is the foundation for calculating the correct dosage in milligrams.
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