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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The goal of hospice care is to prolong life: Hospice care focuses on providing comfort and improving quality of life rather than prolonging life. It is aimed at managing symptoms and supporting patients and families when a cure is no longer possible.
B. Hospice care is limited to clients who are in a health care facility: Hospice care can be provided in various settings, including the patient's home, nursing homes, or hospice facilities. It is not limited to health care facilities.
C. Hospice care is restricted to clients who are terminally ill: Hospice care is specifically designed for individuals who are terminally ill, typically with a prognosis of 6 months or less to live if the disease runs its usual course. This ensures the care is appropriate and focused on end-of-life comfort.
D. Hospice care cannot be discontinued once it is initiated: Hospice care can be discontinued if the patient's condition improves or if they decide to pursue curative treatment. It is not a permanent commitment.

A. Acute pain manifested by client's report. B. Acute pain related to psychosomatic condition. C. Acute pain related to unknown etiology. D. Acute pain related to unknown factors.

Correct Answer is C

Explanation

A. Acute pain manifested by client's report: While this diagnosis reflects the client's report of pain, it does not address the underlying cause or etiology of the pain, which is important for forming an effective care plan.
B. Acute pain related to psychosomatic condition: This diagnosis implies a specific psychosomatic origin for the pain. Since the etiology is unknown, attributing it to a psychosomatic condition may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis is the most appropriate because it acknowledges the presence of acute pain and explicitly notes that the cause is unknown, which aligns with the information provided.
D. Acute pain related to unknown factors: This diagnosis is similar to C, but "unknown factors" is less precise than "unknown etiology." The term "etiology" more accurately describes the underlying cause.

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A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

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