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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.
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When using the SOAP method of charting, S stands for subjective data which means:
- A. patient provided data
- B. all of the answers are correct
- C. observed data
- D. measured data
Correct Answer: A
Rationale: Subjective data (A) includes patient-reported information like pain or symptoms. Observed (C) and measured (D) data are objective, and B is incorrect as only A is accurate.
Patient provided subjective data of intermittent chest pain upon exertion
Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:
- A. a head-to-toe assessment
- B. subjective data collection
- C. objective data collection
- D. Maslow's Hierarchy of Needs
Correct Answer: A
Rationale: A head-to-toe assessment (A) organizes a complete exam systematically. B and C are data types, not approaches, and D prioritizes needs, not physical exams.
Patient with dyspnea
The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:
- A. implementation
- B. evaluation
- C. planning
- D. assessment
Correct Answer: C
Rationale: Planning (C) involves selecting interventions for patient needs, like dyspnea. A, B, and D represent other phases.
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.
Identify the two primary methods used to collect data:
- A. interview and physical examination
- B. review of the doctor's orders and the Kardex
- C. written report by patient and family
- D. review of the chart and the nurse's notes
Correct Answer: A
Rationale: Interview and physical examination (A) collect subjective and objective data directly. B, C, and D are secondary or supportive methods.