The nurse documents in the patient record, "0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.” The most significant statement about the documentation is that it is:
unacceptable because it is vague subjective data without supportive data
good because it shows immediate response to the problem
inadequate because the time of physician notification is not listed
acceptable because it includes assessment, intervention and evaluation
The Correct Answer is D
A. Unacceptable because it is vague subjective data without supportive data: The documentation includes objective data (BP, pulse), a physician notification, an intervention (analgesic), and an outcome.
B. Good because it shows immediate response to the problem: While the response to the problem is immediate, this choice is incomplete as it does not acknowledge that the documentation reflects all aspects of assessment, intervention, and evaluation.
C. Inadequate because the time of physician notification is not listed: While including the exact time of physician notification is best practice, the record still meets documentation standards.
D. Acceptable because it includes assessment, intervention, and evaluation: The note follows the nursing process (assessment, intervention, and response/evaluation), making it acceptable documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. To clarify nursing principles: Nursing orders are action-oriented and not just meant to clarify theoretical principles.
B. To resolve the patient’s problems: Nursing orders focus on patient care interventions that directly address identified problems in the nursing diagnosis.
C. To support physician’s orders: Nursing orders complement medical care but are independent nursing actions, not just support for physician directives.
D. To provide broad, general statements: Nursing orders should be specific, measurable, and actionable, not broad statements.
Correct Answer is C
Explanation
A. Implementation: Implementation occurs after interventions have been planned and involves carrying out those interventions.
B. Evaluation: Evaluation occurs after implementation to assess if the intervention was effective.
C. Planning: The planning phase involves choosing the best interventions based on patient assessment and nursing diagnosis.
D. Assessment: Assessment is gathering information about the patient, not deciding on interventions.
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