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Patient reporting moderate to severe pain
A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (select all that apply)
- A. Repeat the details of the prescription back to the provider
- B. Record the reason for the call made to the provider and the results of the call in the Nurses Notes
- C. Tell the charge nurse that the provider has prescribed morphine by telephone
- D. Refuse to accept the verbal prescription because this is not an emergency
Correct Answer: A,B
Rationale: A: Repeating the prescription ensures accuracy via read-back verification. B: Documenting the call's reason and outcome is essential for legal records. C is good practice but not required, and D is incorrect as verbal orders can be accepted with proper protocol.
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When discovering subjective data, recognize that they relate to:
- A. signs
- B. objective cues
- C. symptoms
- D. observable data
Correct Answer: C
Rationale: Subjective data relates to symptoms (C) reported by the patient, like pain or nausea. Signs (A), objective cues (B), and observable data (D) are objective, measurable findings.
Who should document care in the patient record?
- A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.
- B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.
- C. All staff members should document all of the care that they have provided.
- D. All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.
Correct Answer: C
Rationale: All staff (C) must document their own care for accuracy and accountability. A, B, and D incorrectly assign documentation responsibilities.
Patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated
The nurse documents in the patient record, '0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.' The most significant statement about the documentation is that it is:
- A. unacceptable because it is vague subjective data without supportive data
- B. good because it shows immediate response to the problem
- C. inadequate because the time of physician notification is not listed
- D. acceptable because it includes assessment, intervention and evaluation
Correct Answer: D
Rationale: The documentation (D) includes assessment (pain, vital signs), intervention (analgesic), and evaluation (relief), making it complete. A, B, and C overlook its comprehensive nature.
When documenting events in a patient's chart, the nurse should chart:
- A. the specific time of all sudden changes in the patient's condition
- B. the period the shift covers
- C. every 2 hours
- D. every hour on the hour
Correct Answer: A
Rationale: Charting sudden changes with specific times (A) ensures accuracy and supports care decisions. B, C, and D are less precise or unnecessary.
Select the type of assessment which is performed continuously throughout nurse-patient contact:
- A. focused
- B. body systems
- C. subjective
- D. complete
Correct Answer: A
Rationale: Focused assessments (A) are ongoing, targeting specific issues like pain or breathing during contact. Body systems (B), subjective (C), and complete (D) assessments are not continuous.