Which of the following is an example of good charting?

"No complaints of pain or discomfort."

The patient states, "It feels like a knife stabbing me."

"Lump diminished."

"Patient's condition much better today than yesterday."

Answer and Explanation

The Correct Answer is B

thoroughly. The patient may not have verbalized pain but could still be experiencing it.

B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.

C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).

D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).

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Correct Answer is ["C","D","E"]

Explanation

A. Assistive personnel reports the patient walks with a limp: This is secondhand information (reported by UAP), not directly observed by the nurse.

B. Patient reports pain level as 3 on a scale of 1 to 10: Pain is subjective data because it is based on the patient's self-report.

C. Heart rate 72 beats per minute: Heart rate is measured by the nurse, making it objective data.

D. Respiratory rate 22 per minute with even unlabored respirations: The nurse directly observes and measures respiratory rate, making it objective data.

E. Coughed up 5 mL yellow sputum: The nurse can observe and quantify the sputum (color and volume), making it objective data.

F. Headache in frontal area: A headache is subjective data because only the patient can describe it.

A. signs of fluid overload B. symptoms C. data clustering D. urinary retention

Correct Answer is C

Explanation

A. Signs of fluid overload: Fluid overload presents with edema, crackles in lungs, and increased blood pressure, not dry skin and mucous membranes.

B. Symptoms: Symptoms are subjective (e.g., pain, nausea), while the given findings are observable signs.

C. Data clustering: The nurse groups related signs (flushed skin, dry mucous membranes, elevated temperature) to identify a pattern suggesting dehydration or fever.

D. Urinary retention: Urinary retention is associated with bladder distention and reduced urine output, not dry skin and mucous membranes.

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Which of the following is an example of good charting?

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Naxlex Comprehensive Predictor Exams

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Correct Answer is ["C","D","E"]

Explanation

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

Correct Answer is C

Explanation

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

One benefit of computerized charting is that:

Which of the following is an example of good charting?