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 B

Explanation

A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.

A. Orthostatic hypotension increases a client's risk of a fall. B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. C. Orthostatic hypotension increases a client's risk of a pulmonary emboli D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

Correct Answer is A

Explanation

A. Orthostatic hypotension increases a client's risk of a fall: Correct. Orthostatic hypotension can lead to dizziness or lightheadedness when standing, increasing the risk of falls.
B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: This is not specific enough. Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more when standing.
C. Orthostatic hypotension increases a client's risk of a pulmonary emboli: This is not directly related. Orthostatic hypotension mainly affects balance and fall risk, not the risk of pulmonary emboli.
D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: This is incorrect. Orthostatic hypotension is more commonly assessed by a significant drop in systolic blood pressure rather than diastolic pressure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is essential when restraints are applied to a client?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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