The client developed a slight hematoma on his left forearm. The nurse

The client developed a slight hematoma on his left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, “My arm feels better.” What is documented as the “R” in FOCUS charting?

1. “Infiltrated IV line”
2. “My arm feels better”
3. “Elevation of left forearm”
4. “Slight hematoma on left forearm”

ANSWER

ANS: 2
The “R” in FOCUS charting is the client’s response. In this case, the nurse would document, “My arm feels better.” “Infiltrated IV line” would be documented as “D” referring to data in FOCUS charting. “Elevation of left forearm” is the “A” in FOCUS charting. It describes the ac-tion or nursing intervention. “Slight hematoma on left forearm” is the “D” referring to data in FOCUS charting.