A nurse records the following at 1800: patient states that the abdominal pain is worse now than last night—Betty Smith, RN. The nurse is using which type of charting?
a. PIE documentation
b. SOAP documentation
c. Narrative charting
d. Charting by exception
C
Narrative charting uses a storylike format to document information specific to patient conditions and nursing care. PIE charting focuses on problem, intervention, and evaluation. SOAP documentation addresses subjective data, objective data, assessment, and the plan. Charting by exception reduces the time required to complete documentation, using a flow sheet to indicate normal findings or routine interventions.
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In the operating room, the client tells the circulating nurse that he is going to have the cataract in his left eye removed. The nurse notes that the consent form indicates that surgery is to be performed on the right eye
What is the nurse's best first action? A. Assume that the client is a little confused because he is older and has received midazolam intramuscularly. B. Check to see if the client has received any preoperative medications. C. Notify the surgeon and anesthesiologist. D. Ask the client his name.
A patient with multiple organ dysfunction syndrome is receiving dopamine at a rate of 20 mcg/kg/min. Which of the following actions would the nurse expect the patient to demonstrate?
1. increase in cardiac output 2. increase in urine output 3. increase in peripheral pulses 4. increase in blood pressure
First-line managers can apply Lewin's framework for planned change to nursing care. Which part of Lewin's framework is comparable to the evaluation step of the nursing process?
a. Unfreezing phase b. Moving phase c. Refreezing phase d. Force-field analysis
The nurses on the unit were planning care for a group of clients and determining whether they could best meet client needs in a task or a process group. Their decision was based on the under-standing that a task group focuses on:
1. Relations among the members 2. Communication styles 3. Content issues 4. The "here and now"