A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Client assisted OOB, instructed to splint ABD

Urine collected for UA and C & S

Prescription received for MSO4 4.0 mg PRN pain

12 units of regular insulin administered subcut

Answer and Explanation

The Correct Answer is C

A. "Client assisted OOB, instructed to splint ABD" is clear and uses standard abbreviations (OOB: out of bed, ABD: abdomen).
B. "Urine collected for UA and C & S" is clear and uses standard abbreviations (UA: urinalysis, C & S: culture and sensitivity).
C. "Prescription received for MSO4 4.0 mg PRN pain" is problematic because "MSO4" is an ambiguous abbreviation that can be confused with other medications. It should be written as "morphine sulfate" for clarity. Additionally, the trailing zero in "4.0 mg" can lead to dosing errors; it should be written as "4 mg."
D. "12 units of regular insulin administered subcut" is clear and uses standard terminology (subcut: subcutaneous).

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Correct Answer is B

Explanation

A. This statement describes the current situation, which is part of the "S" (Situation) in SBAR, not the background. Accurate reporting requires separating current findings from background information.
B. Providing the client's history of hypertension is appropriate for the "B" (Background) component. It gives context to the current situation, helping the provider understand potential underlying conditions.
C. This information describes the patient's current assessment and is appropriate for the "A" (Assessment) part of SBAR. Including this in the background can cause confusion and disrupt the communication flow.
D. This statement provides a recommendation and fits into the "R. (Recommendation) part of SBAR. Mixing recommendation with background information can make the communication less clear.

A. Ask a family member to verify the client's identity. B. Check the client's name on the medication administration record (MAR) C. Verify the client's room number D. Ask the client's full name and date of birth.

Correct Answer is D

Explanation

A. Family members are not reliable sources for verifying patient identity.
B. Checking the client's name on the MAR is a part of the process but alone is not sufficient for identification.
C. Room numbers can change or be occupied by different patients; they do not verify patient identity.
D. Asking the client's full name and date of birth ensures direct confirmation from the patient, which is the most reliable method of identification.

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A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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