The documentation that reflects implementation is:

Patient will ambulate for 15 minutes after lunch.

Patient selected low-sugar snacks independently.

Patient was medicated with Tylenol 500 mg PO for pain.

Patient participated in group therapy session without prompting.

Answer and Explanation

The Correct Answer is C

Choice A rationale

"Patient will ambulate for 15 minutes after lunch" is a planned nursing intervention or goal, outlining a future action for the patient. It describes what is expected to happen, not what has already been implemented and documented.

Choice B rationale

"Patient selected low-sugar snacks independently" describes an observation of the patient's behavior and adherence to a dietary plan. While it reflects an action, it doesn't explicitly document a direct nursing intervention performed.

Choice C rationale

"Patient was medicated with Tylenol 500 mg PO for pain" clearly documents the implementation of a specific nursing intervention – the administration of medication. It states what was done, including the drug, dosage, route, and reason.

Choice D rationale

"Patient participated in group therapy session without prompting" describes the patient's participation in a therapeutic activity. While nurses may facilitate or encourage participation, this statement focuses on the patient's action rather than a direct nursing intervention performed on the patient. .

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Correct Answer is A

Explanation

Developing a care plan is a collaborative process that ideally involves the physician, the patient, the nurse, and other members of the healthcare team. The physician's input is vital for medical diagnoses, treatment orders, and overall medical management, which are integral components of the patient's comprehensive care plan.

A. Client administered nitroglycerin. B. Client reports chest pain after mowing the lawn this morning. C. Client's blood pressure is 182/98 mmHg. D. Client's skin is pale and diaphoretic.

Correct Answer is B

Explanation

Choice A rationale

Client administered nitroglycerin is objective data because it is a documented action performed by the client and can be verified. Subjective data, on the other hand, comes from the client's perspective.

Choice B rationale

Client reports chest pain after mowing the lawn this morning is subjective data because it is a statement made by the client about their experience. It describes their feelings and circumstances as they perceive them.

Choice C rationale

Client's blood pressure is 182/98 mmHg is objective data because it is a measurable physiological parameter obtained through assessment. It is a factual finding that can be directly observed and recorded.

Choice D rationale

Client's skin is pale and diaphoretic is objective data because these are observable physical signs noted by the nurse during assessment. They are factual descriptions of the client's physical condition.

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The documentation that reflects implementation is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

True or False: An important consideration when developing the care plan is to ensure that the physician is involved in the process.

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

The nurse is caring for a patient who came to the hospital with acute shortness of breath.What is the priority action of the nurse as the assessment process is started?

The patient has a goal of maintaining urinary output of at least 80 mL/hour as part of the nursing care plan.However, the patient's urinary output for the shift was only 20 mL/hour.What is the appropriate action of the nurse?

The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.The patient developed a large hematoma where the laboratory technician had drawn blood earlier in the shift.Which statement is appropriate to enter in the patient's chart?

The nurse is completing the charting after a patient suffered a fall.Which statement is appropriate for the nurse to include in the description of the incident?

Which patient's needs must be addressed first by the nurse?

Which chart entry represents appropriate documentation about the patient's pain assessment?

A nurse is reviewing new orders for an ambulate patient four times a day.

What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?