A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Client assisted OOB, instructed to splint ABD

Urine collected for UA and C & S

Prescription received for MSO4 4.0 mg PRN pain

12 units of regular insulin administered subcut

Answer and Explanation

The Correct Answer is C

A. "Client assisted OOB, instructed to splint ABD" is clear and uses standard abbreviations (OOB: out of bed, ABD: abdomen).
B. "Urine collected for UA and C & S" is clear and uses standard abbreviations (UA: urinalysis, C & S: culture and sensitivity).
C. "Prescription received for MSO4 4.0 mg PRN pain" is problematic because "MSO4" is an ambiguous abbreviation that can be confused with other medications. It should be written as "morphine sulfate" for clarity. Additionally, the trailing zero in "4.0 mg" can lead to dosing errors; it should be written as "4 mg."
D. "12 units of regular insulin administered subcut" is clear and uses standard terminology (subcut: subcutaneous).

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Correct Answer is D

Explanation

A. This statement is an objective finding, describing an action taken (administration of nitroglycerin).
B. This statement describes objective observations of the client's physical appearance.
C. This statement provides objective data about the client's blood pressure.
D. This statement reflects the client's report of symptoms, making it part of the subjective component of SOAP documentation.

A. ask the patients their names B. ask another nurse about their identities C. check the patients' ID bands and patient information D. verify their names with the family members

Correct Answer is C

Explanation

A. Asking patients their names can help, but it is not the most reliable method, especially if patients are confused or unable to communicate.
B. Asking another nurse about their identities can introduce errors and is not a standard practice for patient identification.
C. Checking the patients' ID bands and patient information ensures accurate identification using multiple identifiers (e.g., name, birth date, medical record number), adhering to best practices for patient safety.
D. Verifying names with family members can be helpful but is not as reliable or standardized as checking ID bands and patient information.

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A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component?

Correct Answer is D

Explanation

Upon receiving the assignment for the evening, a nurse notices that two of the patients have the same name. The best way to identify two patients on a medical unit who have the same name is to:

Correct Answer is C

Explanation

A nurse is receiving a telephone prescription for a client and documents it as atorvastatin 80 PO BID. Which of the following elements should the nurse identify is missing from the prescription?

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A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?