A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?
12/18/200XX 0915 Morphine 2 mg IV for incisional pain. TOJ Winds. RN, read back
12/16/2000x 0915 Morphine. 2 mg IV every 4 hours for incisional pain TOJ Winds, RN
12/16/20XX 0915 Morphine, 2 mg IV every 4 hours for incisional pain. TO Dr. Day Winds, RN, read back
12/16/2000x 0915 Morphine, 2 mg IV every 4 hours for incisional pain. VO Dr. Day Winds, RN, read back.
The Correct Answer is C
A: This option is incorrect because the date is wrong, and it uses "TOJ" which is not a standard abbreviation in medical documentation. The correct format should include the date the order was received, the medication and dosage, frequency, reason for administration, and the initials of the person taking the order along with a 'read back' confirmation.
B: This choice is incorrect because it lacks the 'read back' confirmation which is a critical part of telephone orders to ensure accuracy. Additionally, the use of "TOJ" is incorrect, and the date format is inconsistent with standard medical records.
C: This is the correct choice because it includes all necessary information: the correct date, medication and dosage, frequency, reason for administration, and it correctly identifies the order as a telephone order with "TO" followed by the doctor's name, and includes the nurse's initials with a 'read back' confirmation.
D: This option is incorrect because it uses "VO" which stands for verbal order, not a telephone order. It also lacks the full date and has an inconsistent date format. The 'read back' confirmation is present, but the incorrect order type makes this entry invalid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client to demonstrate walking with the cane: Correct. Evaluation involves assessing the client’s ability to perform the learned skill, which is done by asking the client to demonstrate walking with the cane.
B. Show the client a video about walking with a cane: This is part of the teaching process, not evaluation. It is used to provide information but does not assess the client's understanding or ability.
C. Identify short-term goals for the client: This is part of the planning stage, where goals are set to guide the teaching and learning process, not part of evaluation.
D. Determine the client's readiness to learn: This is an initial assessment step before teaching begins, not part of the evaluation process after teaching has occurred.
Correct Answer is C
Explanation
A. Bronchial airway constriction: In the fight-or-flight response, bronchial airways actually dilate to increase airflow to the lungs, rather than constricting.
B. Hypoglycemia: The fight-or-flight response typically leads to increased blood glucose levels (hyperglycemia) to provide quick energy, not decreased levels.
C. Dilated pupils: During the fight-or-flight response, pupils dilate to improve vision and help the individual better detect threats. This is a classic manifestation of this stress response.
D. Decreased blood pressure: The fight-or-flight response generally increases blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
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