A nurse is preparing to document the care plan for a client who has a problem-oriented medical record (POMR).
Which of the following actions should the nurse take?
(Select all that apply.).
Generate the care plan from the database.
Number the care plan to correspond to the problem list.
Repeat assessments and interventions that apply to more than one problem.
Update the problem list as needed.
Use a standardized format for chart entries.
Correct Answer : B,D
The nurse should number the care plan to correspond to the problem list and update the problem list as needed. These actions are consistent with the principles of the problem-oriented medical record (POMR), which is a method of organizing patient information by the health problems that require attention. The POMR includes a patient database, a problem list, a plan of care, and progress notes.
Choice A is wrong because the nurse should not generate the care plan from the database, but rather from the problem list. The problem list is the centerpiece of the POMR and reflects the patient’s current health status and needs.
Choice C is wrong because the nurse should not repeat assessments and interventions that apply to more than one problem, but rather use cross-referencing to avoid duplication and confusion.
Choice E is wrong because the nurse should not use a standardized format for chart entries, but rather use a SOAP format (subjective, objective, assessment, plan) or a modified version of it (such as SOAPIE or SOAPIER) to document each problem and its progress.
The normal ranges for some common laboratory tests are:.
• CBC (complete blood count):.
➤ Hemoglobin: 13.5-17.5 g/dL (male), 12-16 g/dL (female).
➤ Hematocrit: 38.8-50% (male), 34.9-44.5% (female).
➤ White blood cell count: 4.5-11 x 10^9/L.
➤ Platelet count: 150-450 x 10^9/L.
• SMAC (sequential multiple analysis computer):.
➤ Sodium: 135-145 mEq/L.
➤ Potassium: 3.5-5 mEq/L.
➤ Chloride: 98-106 mEq/L.
➤ Bicarbonate: 22-29 mEq/L.
➤ Blood urea nitrogen: 7-20 mg/dL.
➤ Creatinine: 0.6-1.2 mg/dL (male), 0.5-1.1 mg/dL (female).
➤ Glucose: 70-110 mg/dL.
➤ Calcium: 8.5-10.2 mg/dL.
• EKG (electrocardiogram):.
➤ Heart rate: 60-100 beats per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“Instructed the client on low-sodium diet and exercise.”
This is the action that the nurse took to address the client’s problem of hypertension.
The action should describe the nursing intervention that was performed to help the client achieve the expected outcome.
Choice A is wrong because it is not an action, but a data.
Data is the information that the nurse collected about the client’s condition, such as vital signs, symptoms, or test results.
Data should be factual and objective.
Choice C is wrong because it is not an action, but a response.
Response is the outcome or result of the nursing intervention, such as the client’s reaction, behavior, or change in condition.
Response should be measurable and evaluative.
Choice D is wrong because it is not an action, but a focus.
Focus is the reason or purpose for writing the note, such as a nursing diagnosis, a change in condition, or a patient education need.
Focus should be concise and specific.
DAR format is a method of nursing documentation that stands for Data, Action, and Response.It is a form of focus charting that records significant events or changes in the client’s condition that require nursing care.DAR notes are organized, concise, and informative, and they help to communicate the nursing process and plan of care among health care providers.
Correct Answer is C
Explanation
“Administered bisacodyl suppository as prescribed.”.
The PIE format is a method of documentation that states theproblemor diagnosis (P), theinterventionor action the nurse takes (I), and theevaluationof the results (E).It eliminates the need for a traditional care plan by incorporating it into the progress notes.
The intervention is the action that the nurse takes to address the problem.
In this case, the problem is constipation, and the intervention is administering a bisacodyl suppository as prescribed by the physician.
This is a specific and measurable action that can be evaluated later.
Choice A is wrong because it is not an intervention, but a health promotion activity.
Encouraging the client to increase fluid and fiber intake is a good practice, but it is not directly related to the problem of constipation.
Choice B is wrong because it is not an intervention, but an assessment.
Assessing the client’s bowel sounds and abdominal distension is part of the data collection process, but it does not solve the problem of constipation.
Choice D is wrong because it is not an intervention, but an evaluation.
Evaluating the client’s response to the suppository is the last step of the PIE format, where the nurse determines if the intervention was effective or not.
It does not describe what the nurse did to address the problem of constipation.
The normal range for bowel movements varies from person to person, but generally, having less than three bowel movements per week is considered constipation.Constipation can be caused by various factors, such as medication side effects, dehydration, low-fiber diet, lack of physical activity, or underlying medical conditions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.