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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.
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How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?
- A. It serves as a reminder of human growth and development across the life span
- B. It helps in prioritizing nursing diagnoses and care
- C. It outlines the basic psychological needs that people have when they are hospitalized and feel anxiety
- D. It is a framework for thinking critically
Correct Answer: B
Rationale: Maslow's hierarchy (B) prioritizes care by addressing physiological needs first, then safety, love, esteem, and self-actualization. A, C, and D are less accurate uses.
Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:
- A. ethically can look at a friend's chart to see the diagnosis
- B. shares information from a chart to protect a friend
- C. knows that only the Patient's Bill of Rights advocates confidentiality
- D. reads charts only for professional reasons
Correct Answer: D
Rationale: Nurses must access records only for professional reasons (D) to comply with HIPAA. A and B violate confidentiality, and C is incorrect as multiple laws protect privacy.
Patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation
During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:
- A. signs of fluid overload
- B. symptoms
- C. data clustering
- D. urinary retention
Correct Answer: C
Rationale: Grouping signs like flushed skin and fever (C) is data clustering, suggesting dehydration or infection. Fluid overload (A) shows edema, symptoms (B) are subjective, and urinary retention (D) involves bladder issues.
On what form/forms should the nurse chart when administering a narcotic?
- A. Physician's Order Sheet
- B. Narcotic Administration Sheet
- C. Care Plan
- D. MAR and Narcotic Administration Sheet
Correct Answer: D
Rationale: Narcotics are documented on both the MAR (Medication Administration Record) (D) for all medications and the Narcotic Administration Sheet for controlled substances to ensure tracking and compliance. A, B alone, and C are incorrect.
During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?
- A. block
- B. by exception
- C. focused
- D. SOAP
Correct Answer: B
Rationale: Charting by exception (B) documents only significant changes or deviations, not routine care. Block (A) covers entire shifts, focused (C) targets specific issues, and SOAP (D) follows a structured format.