A nurse is reviewing the documentation system of a client’s chart.
Which of the following is an advantage of using a source-oriented record?
It encourages collaboration among health care providers.
It organizes the data according to the client’s problems.
It tracks the status of each problem using a problem list.
It keeps data from each person or department in a separate section.
The Correct Answer is D
It keeps data from each person or department in a separate section. A source-oriented record is a type of documentation system that organizes the data according to the source of information, such as the physician, nurse, laboratory, or physical therapy. This format has the advantage of making it easy to locate and trace the information from each person or department who provided care to the client.
Choice A is wrong because it does not encourage collaboration among health care providers. In fact, a source-oriented record may hinder communication and coordination of care because the data are fragmented and scattered throughout the chart.
Choice B is wrong because it does not organize the data according to the client’s problems. A problem-oriented medical record (POMR) is a different type of documentation system that arranges the data based on the problems identified by the health care team. The POMR has four components: database, problem list, plan of care, and progress notes.
Choice C is wrong because it does not track the status of each problem using a problem list. This is also a feature of the POMR, not the source-oriented record. A problem list is a numbered list of the client’s current and resolved problems that serves as an index to the progress notes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
The nurse shouldnumber the care plan to correspond to the problem listandupdate 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.
Correct Answer is B
Explanation
“The client reports feeling less pain in his left leg.”
This is the subjective data because it is based on the client’s own perception and feelings.Subjective data is what the client tells the nurse or what the nurse observes from the client’s behavior.
Choice A is wrong because it is objective data, which is measurable and observable by the nurse or other healthcare providers.Objective data is what the nurse sees, hears, feels, or smells.
Choice C is wrong because it is also objective data, as it can be measured by the nurse using a goniometer or other tools.
Choice D is wrong because it is also objective data, as it can be observed by the nurse or documented in the care plan.
Normal ranges for vital signs are as follows:.
• Blood pressure: 90/60 mmHg to 120/80 mmHg.
• Pulse rate: 60 to 100 beats per minute.
• Respiratory rate: 12 to 20 breaths per minute.
• SpO2: 95% to 100%.
• Temperature: 36.5°C to 37.5°C.
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