When the nurse charts only additional treatments done, changes in patient condition, and new concerns, the system of documentation is:
a. SOAP.
b. block.
c. CBE.
d. focus.
C
Charting additional treatments done, changes in a patient's condition, and new concerns during the shift is charting by exception (CBE).
You might also like to view...
The MOST appropriate time for a nurse to complete the initial nursing assessment of a client admitted to a health care facility is:
a. prior to admission by the office or clinic nurse b. within 8 hours of admission c. after the first 24 hours or the acute phase of health care has passed d. just before the client's discharge to home or to a rehabilitation center
The nurse is preparing a client for diagnostic studies requiring the administration of contrast media. Which action by the nurse is the priority in this situation?
1. Obtaining informed consent 2. Obtaining results of lab tests 3. Checking for allergies 4. Checking if routine medications are to be held
A 57-year-old woman was diagnosed with osteoarthritis (OA) by her primary care provider several months ago and claims that she is achieving acceptable control of her symptoms by taking acetaminophen several times daily. The nurse should perform further assessment to ensure that the patient is doing which of the following?
A) Taking her acetaminophen with food B) Not exceeding 2,000 mg of acetaminophen in any 24-hour period C) Drinking sufficient amounts of fluids D) Not exceeding three doses per day
The nurse is planning a class for unlicensed assistive personnel
Which factors should the nurse describe as causing interference with accurate pulse oximeter readings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Ambient light 2. Nail polish 3. Inhalation injuries 4. Arterial pulse deficit 5. Sensor placement on the ear