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. Current Medical condition: The situation component of ISBARR focuses on the patient's current medical condition and why they are in the facility. It provides a snapshot of the client's immediate situation.
B. List of medications: While important, the list of medications is more relevant to the background or assessment components of the report.
C. Vital signs: Vital signs are part of the assessment, providing data on the client’s current health status.
D. Treatment: Treatment information falls under the recommendation or background sections of the report, detailing the plans or historical context rather than the immediate situation.
Correct Answer is C
Explanation
A. Grandparents: While grandparents can provide valuable information, parents are typically the primary source of information about a child’s medical history, current symptoms, and behavioral changes.
B. Admitting provider: The admitting provider's role is to assess and diagnose the client. While they provide essential clinical information, they are not the primary source for personal and historical data about the client.
C. Parents: Parents are the most reliable source of information regarding the toddler's medical history, current condition, and any changes in behavior or health. They are most familiar with the child’s day-to-day health and medical background.
D. Medical record: Although the medical record contains important information, it may not have the most recent updates or contextual details that parents can provide. It is important to corroborate the information in the medical record with input from the parents.
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