A nurse is using the SOAPIER format to document the progress notes of a client who has diabetes mellitus.
The nurse needs to write an intervention entry in the SOAPIER format.
Which of the following is an example of an intervention entry in the SOAPIER format?
“I feel thirsty and hungry all the time.”.
Blood glucose level is 250 mg/dL before lunch.
Instructed the client on how to use a glucometer at home.
Impaired glucose tolerance related to insufficient insulin production.
“I will check my blood sugar before each meal and at bedtime.”.
The Correct Answer is C
Instructed the client on how to use a glucometer at home.
This is an example of an intervention entry in the SOAPIER format, which stands for subjective, objective, assessment, plan, intervention, and evaluation. An intervention entry describes any actions that were taken to support the patient based on the assessment and plan.
In this case, the nurse provided patient education on how to monitor blood glucose levels at home using a glucometer.
Choice A is wrong because it is an example of a subjective entry, which includes anything related to what the patient has told the nurse. This should be recorded exactly as the patient reports and in quotation marks.
Choice B is wrong because it is an example of an objective entry, which consists of any measurable observations that the nurse makes during the patient assessment. This includes vital signs, laboratory results, physical findings, and other data that can be verified.
Choice D is wrong because it is an example of an assessment entry, which is the nurse’s interpretation of the subjective and objective information and conclusions regarding the patient’s condition. This may include nursing diagnoses, problem statements, or clinical impressions.
Choice E is wrong because it is an example of an evaluation entry, which describes the result of any interventions and whether they achieved the desired outcomes. This may include patient feedback, changes in condition, or need for further action.
Normal ranges for blood glucose levels vary depending on the type of test and the time of day. Generally, a normal fasting blood glucose level is between 70 and 100 mg/dL, while a normal postprandial (after meal) blood glucose level is less than 140 mg/dL. A blood glucose level of 250 mg/dL before lunch indicates hyperglycemia (high blood sugar), which is a common complication of diabetes mellitus.
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Related Questions
Correct Answer is C
Explanation
The client’s oxygen saturation level has improved from 88% to 95% after receiving oxygen therapy for 24 hours.
This is an example of an evaluation entry in the PIE documentation system because it describes the outcome of the intervention (oxygen therapy) for the problem (low oxygen saturation level) using objective data (percentage).
Other choices are wrong because:.
• Choice A: The client has been coughing less frequently and reports feeling less short of breath.
This is an example of an intervention entry because it describes the actions taken by the nurse to address the problem (coughing and shortness of breath).
• Choice B: The client has a productive cough with yellowish sputum and crackles in the lower lobes of both lungs.
This is an example of a problem entry because it identifies the signs and symptoms of the health condition (pneumonia).
• Choice D: The client will maintain a normal oxygen saturation level of at least 92% with supplemental oxygen as needed.
This is an example of a plan entry because it states the expected outcome or goal for the problem (low oxygen saturation level).
The PIE documentation system is a process-oriented system that uses the acronym PIE to document theProblem,Intervention, andEvaluation of the patient’s progress.It integrates care planning with progress notes and does not separate the patient from the environmental influences.The normal oxygen saturation level for healthy adults is between 95% and 100%.
Correct Answer is ["A","B","D"]
Explanation
These are appropriate components of the plan in the SOAP format.SOAP stands forSubjective, Objective, Assessment, Planand it is a form of written documentation many healthcare professions use to record a patient or client interaction.
• Ais correct because monitoring blood pressure and pulse every 4 hours is an objective and measurable intervention that can help evaluate the patient’s condition and response to treatment.
• Bis correct because educating the client about dietary sodium restriction is an intervention that can help prevent or reduce hypertension and its complications.
• Dis correct because evaluating the effectiveness of antihypertensive medication is an intervention that can help assess the patient’s progress and adjust the treatment plan accordingly.
• Cis wrong because assessing for signs of orthostatic hypotension is not an intervention, but an observation that belongs to the objective section of the SOAP note.
• Eis wrong because identifying the risk factors for developing hypertension is not an intervention, but an assessment that belongs to the assessment section of the SOAP note.
Normal ranges for blood pressure are<120/80 mmHgfor normal,120-129/<80 mmHgfor elevated,130-139/80-89 mmHgfor stage 1 hypertension, and≥140/≥90 mmHgfor stage 2 hypertension.Normal ranges for pulse rate are60-100 beats per minutefor adults.
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