A nurse is documenting in a client's electronic medical record. Which of the following entries should the nurse use?

Ativan 1 mg IV given at 1030 following OR call

Acetaminophen 500 mg given for pain

MgSO4 infusing via IV pump

Insulin 5U administered SQ

Answer and Explanation

The Correct Answer is A

A. Ativan 1 mg IV given at 1030 following OR call. This is correct. The entry is clear and includes the medication name, dose, route, and time of administration.
B. Acetaminophen 500 mg given for pain. The entry does not specify the route of administration or the time it was given.
C. MgSO4 infusing via IV pump: This is incorrect. Abbreviations like "MgSO4" can be confusing or misinterpreted. It should be written as "magnesium sulfate."
D. Insulin 5U administered SQ: This is incorrect. The entry uses the abbreviation "U" for units, which can be misinterpreted. It should be written as "units" and specify the exact time and site of administration.

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Correct Answer is B

Explanation

A. Hgb: A hemoglobin level of 11.1 mg/dL is lower than normal, indicating anemia, which could be concerning but might not be the most urgent issue compared to other findings.
B. Urinalysis results: Positive urine ketones indicate ketonuria, which is significant in the context of hyperemesis gravidarum and may reflect severe dehydration or malnutrition. This finding should be reported to the provider.
C. Intake: The client’s intake of 50% of the meal without emesis is a relevant detail but does not indicate a severe immediate issue compared to the urinalysis results.
D. Temperature: A temperature of 37.2° C (99° F) is slightly elevated but not extremely concerning in this context compared to other findings like ketonuria.

A. Provide information about the risks of a surgical procedure to the client. B. Request the client sign the informed consent form after administering a preoperative sedative. C. Mark the client's surgical site with a small strip of nonporous tape. D. Call a "time out" to verify client identity before starting a surgical procedure.

Correct Answer is D

Explanation

A. Provide information about the risks of a surgical procedure to the client. Providing risk information is part of informed consent, not specifically part of Universal Protocol.
B. Request the client sign the informed consent form after administering a preoperative sedative. Informed consent should be obtained before administering sedatives to ensure the client is fully aware and able to consent.
C. Mark the client's surgical site with a small strip of nonporous tape. The surgical site should be marked with a permanent marker to ensure it remains visible and clear throughout the surgical preparation and procedure.
D. Call a "time out" to verify client identity before starting a surgical procedure. This is correct. The Universal Protocol includes a "time out" to verify the correct patient, procedure, and site before starting the surgery.

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A nurse is documenting in a client's electronic medical record. Which of the following entries should the nurse use?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse manager is developing an in-service about The Joint Commission's National Patient Safety Goals for a group of surgical nurses. Which of the following information regarding Universal Protocol should the nurse include in the in-service?

Correct Answer is D

Explanation

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