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 C

Explanation

A. Checking the pulse rate for 30 seconds and multiplying by 2 may not be accurate enough for a medication like digoxin, which requires precise monitoring.
B. Increasing sodium intake is not recommended for heart failure patients as it can worsen fluid retention and exacerbate symptoms.
C. Digoxin can cause bradycardia; therefore, it is crucial for clients to monitor their heart rate and contact their healthcare provider if it falls below 60/min to avoid adverse effects.
D. Taking digoxin with food can help with nausea but is not as critical as monitoring heart rate for potential toxicity.

A. Client administered nitroglycerin 0.3 mg SL for. chest pain B. Client's skin is pale and diaphoretic C. Client's blood pressure is 182/98 mm Hg D. Client reports chest pain after mowing lawn' this morning

Correct Answer is D

Explanation

A. This statement is an objective finding, describing an action taken (administration of nitroglycerin).
B. This statement describes objective observations of the client's physical appearance.
C. This statement provides objective data about the client's blood pressure.
D. This statement reflects the client's report of symptoms, making it part of the subjective component of SOAP documentation.

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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

The nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart failure. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component?

Correct Answer is D

Explanation

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