The following statement: Upon exertion, the client is wheezing ...

[jparksx]

The following statement: Upon exertion, the client is wheezing and experiencing some dysp-nea, is an example of:
 
  1. The P of PIE
  2. FOCUS documentation
  3. The R in DAR documentation
  4. The S in SOAP documentation

Question 2

Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?
 
  1. 1230Client's vital signs taken.
  2. 0700Client drank adequate amount of fluids.
  3. 0900Demerol given for lower abdominal pain.
  4. 0830Increased IV fluid rate to 100 mL/hr according to protocol.

[jamesnevil303]

Answer to Question 1

ANS: 1
These data are examples of the P of PIE because they describe the problem. FOCUS charting does not concentrate on only problems. It is structured according to a client's concerns. The R in DAR documentation is the response of the client. This situation describes the client's problem, not the client's response. The S in SOAP documentation represents subjective data (verbaliza-tions of the client).

Answer to Question 2

ANS: 4
Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating adequate is subjective, not objective. This notation (0900) does not have the client describe his or her pain or rate it ac-cording to a pain scale for comparison later. It also does not indicate whether the client's pain was in the lower left or lower right quadrant, or both.

[jparksx]

Excellent

[bulacsom]

Gracias!