A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider?

A) Teach the use of an incentive spirometer to a postoperative client:
Teaching a patient how to use an incentive spirometer involves assessment, education, and clinical judgment. This task requires the nurse's expertise to ensure that the patient understands how to use the device correctly and to assess for any potential complications, such as inadequate lung expansion.

B) Irrigate and perform a dressing change for a client who has a pressure injury wound:
Irrigating and changing the dressing of a pressure injury involves clinical judgment, the need for sterile technique, and the assessment of the wound. These tasks should be performed by a registered nurse (RN), who can assess the condition of the wound, evaluate for signs of infection, and make decisions regarding further care.

C) Administer oral PRN pain medication to a client who has arthritis:
Administering PRN pain medication requires assessment of the patient's pain level, consideration of the medication’s effects, and clinical judgment regarding the appropriateness of the medication. This is a nursing responsibility because it involves both medication management and the evaluation of therapeutic effects.

D) Obtain a daily weight on a client who has heart failure:
Obtaining a daily weight is a task that can be safely delegated to an assistive personnel (AP). Weight is an important measurement for monitoring fluid status, especially in clients with heart failure. The AP can accurately weigh the client, ensuring that the same scale and conditions (such as time of day, after the patient has voided) are followed each time.

A) SOAP documentation:
SOAP (Subjective, Objective, Assessment, Plan) documentation is a method used for organizing and documenting client information. It focuses on both subjective and objective data, as well as the assessment and plan. While SOAP helps structure the documentation of patient conditions and interventions, it does not specifically focus on documenting only unexpected findings. It is a more comprehensive approach that includes normal and abnormal findings, not just the unexpected ones.

B) Focus charting (DAR):
Focus charting (DAR) is based on a client-centered approach and uses the components of Data, Action, and Response. It is a way of documenting observations and interventions, particularly in relation to specific patient problems or conditions. Focus charting is more about the care provided, responses to interventions, and client outcomes. While it may include unexpected findings, it doesn’t limit documentation exclusively to abnormal or unexpected events.

C) Charting by exception (CBE):
Charting by exception (CBE) is a documentation method that focuses on recording only the significant deviations from the norm. It emphasizes noting any abnormal or unexpected findings, and everything that is normal is assumed to be within expected limits and not documented. This method reduces the amount of documentation by excluding routine information and only highlighting significant, unexpected findings. Therefore, CBE is the correct answer in this scenario, as it involves documenting only unexpected or abnormal findings related to the client's condition.

D) Problem-oriented medical record (POMR):
POMR is a method of documentation that organizes client care around specific problems or diagnoses. It includes the identification of problems, interventions, and outcomes. While POMR focuses on client problems and plans of care, it does not specifically focus on documenting only unexpected findings. It may include both normal and abnormal findings related to each identified problem.