A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.

The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

Redness, swelling, and warmth of the affected area.

Pain level rated as 8/10 on a numerical scale C.

Wound culture results pending.

Risk for infection related to impaired skin integrity.

Applied moist heat compresses to the wound site.

Answer and Explanation

Correct Answer : A,B

These are the only options that describe the subjective and objective data of the patient, which are part of the SOAP documentation method. SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.

Choice C is wrong because wound culture results are not part of the assessment entry in SOAP documentation. They are part of the investigation results, which are usually documented in the objective section.

Choice D is wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment. Nursing diagnoses are usually documented in the plan section of SOAP documentation.

Choice E is wrong because applied moist heat compresses to the wound site is an intervention, not an assessment. Interventions are also documented in the plan section of SOAP documentation.

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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Correct Answer is B

Explanation

It allows access to client information from multiple locations.

This is an advantage of using a computerized system for documentation and reporting because it enables health care providers to access relevant and updated information about their clients from different locations, such as hospitals, clinics, or home care settings.This can improve the quality and continuity of care, as well as facilitate communication and collaboration among different members of the health care team.

Choice A is wrong because it is not true that a computerized system eliminates errors and inaccuracies in documentation.While a computerized system can reduce some types of errors, such as illegible handwriting or misplaced files, it can also introduce new types of errors, such as data entry mistakes, software glitches, or system failures.

Choice C is wrong because it is not true that a computerized system reduces the need for verbal or written communication among health care providers.On the contrary, a computerized system can enhance communication by allowing health care providers to share information more easily and quickly, but it does not replace the need for verbal or written communication to clarify, confirm, or discuss the information.

Choice D is wrong because it is not true that a computerized system protects client information from unauthorized disclosure or alteration.

While a computerized system can provide some security features, such as passwords, encryption, or audit trails, it can also pose some risks, such as hacking, phishing, or malware attacks.Therefore, health care providers need to follow ethical and legal guidelines to ensure the confidentiality and integrity of client information in a computerized system.

A. Data. B. Problem. C. Focus. D. Assessment.

Correct Answer is C

Explanation

Focus.

Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.

The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.

Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.

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A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

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Naxlex Comprehensive Predictor Exams

What is one advantage of using a computerized system for documentation and reporting?

Correct Answer is B

Explanation

A nurse is using the focus charting method to document care for a client who has diabetes mellitus. Which of the following terms should the nurse use to begin each entry?

Correct Answer is C

Explanation

A nurse is participating in a care plan conference for a client who has multiple chronic conditions and complex care needs. What is the main purpose of this meeting?

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?

Which of these statements about documentation are true? (Select all that apply.).

A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility. Which of the following data should the nurse record on this type of document?

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.

The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.