A nurse is documenting client care. Which of the following abbreviations should the nurse use?
"OJ" for orange juice
"SS" for sliding scale
"SQ" for subcutaneous
"BRP" for bathroom privileges
The Correct Answer is D
a. "OJ" for orange juice is not recommended. While it might seem straightforward, "OJ" could be confused with "oj" or other abbreviations, leading to potential confusion. It's better to write out "orange juice."
b. "SS" for sliding scale is not recommended" could be misinterpreted or confused with other meanings. It's safer to write out "sliding scale."
c. SQ is commonly mistaken as “5 every”. Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly).
d. This is a commonly accepted abbreviation in medical documentation, meaning bathroom privileges.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The client has expressed a lack of understanding about the procedure, which indicates that they may not have received sufficient information or clarification. It is important to notify the provider so they can ensure the client fully understands the procedure before giving informed consent.
Choice B reason:
The nurse should provide basic information and answer questions within their scope, but detailed explanations about the procedure are best provided by the provider who is performing the surgery.
Choice C reason:
While brochures can be helpful, they do not replace the need for direct, clear communication with the healthcare provider about the specific details of the surgery.
Choice D reason:
An incident report is not necessary in this context as the situation is related to informed consent and not an error or safety issue.
Correct Answer is C
Explanation
Choice A reason:
Documenting the fluid infusion in the client's chart: While documenting the fluid infusion is important, assessing the client's vital signs should take priority to ensure their immediate safety and well-being.
Choice B reason:
Completing an incident report is incorrect Completing an incident report is a necessary step to document the error and initiate appropriate follow-up actions, but it should come after assessing the client's condition.
Choice C reason
Obtaining the client's vital signs is the correct answer. The correct first action for the nurse to take in this situation is to obtain the client's vital signs. Administering an excessive amount of IV fluid could potentially have adverse effects on the client's cardiovascular system, including fluid overload, electrolyte imbalances, and changes in blood pressure. Monitoring the client's vital signs will help assess their current condition and any potential complications resulting from the excess fluid administration.
Choice D reason
Reporting the incident to the unit manager is incorrect. Reporting the incident to the unit manager is important for organizational awareness and accountability, but the nurse's first responsibility is to assess the client's vital signs and address any potential complications.
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