A nurse is using the SOAP format to write a progress note for a client who has impaired physical mobility.

Which of the following statements should the nurse include as the subjective data?

“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.

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.