The patient's medical record contains the following documentation:

06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge intravenous catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN
Which type of charting has the nurse used?
1) Narrative
2) Focus
3) SOAP
4) PIE


ANS: 1

Nursing

You might also like to view...

A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply

A) Diarrhea B) Nausea and vomiting C) Frequent infections D) Fatigue from anemia E) Easy bruising

Nursing

Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias?

a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

Nursing

What action is appropriate for the nurse to implement when monitoring the ECG of a patient with a transvenous ventricular demand pacemaker? The ECG strip shows QRS complexes without pacer spikes

1. Plan for immediate removal of pacer lead wires. 2. Continue to observe the patient and the ECG rhythm. 3. Call the health care provider and explain that capture has been lost. 4. Call a code for ventricular fibrillation.

Nursing

A client is to receive an implantable contraceptive. The nurse describes this contraceptive as containing:

A) Synthetic progestin B) Combined estrogen and progestin C) Concentrated spermicide D) Concentrated estrogen

Nursing