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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Performing a physical examination involves the systematic assessment of a patient's body to identify signs of health or illness. Listening to lung sounds, palpating peripheral pulses, and obtaining vital signs are all fundamental components of a physical examination aimed at gathering objective data about the patient's current condition.
Choice B rationale
Establishing priorities for outcomes involves setting goals for patient care based on identified nursing diagnoses and collaborative problems. While the nurse's assessment data will inform the development of outcomes, the initial actions described focus on data collection, not outcome identification.
Choice C rationale
Demonstrating diagnostic reasoning is the cognitive process of analyzing assessment data to arrive at a nursing diagnosis or identify a collaborative problem. While the nurse is gathering data that will contribute to diagnostic reasoning, the actions described are the data collection phase itself, not the analysis.
Choice D rationale
Setting time frames for interventions involves establishing specific schedules for nursing actions aimed at achieving patient outcomes. The nurse's immediate actions upon the patient's arrival are focused on rapid assessment to understand the patient's immediate needs, not on scheduling future interventions.
Correct Answer is D
Explanation
Choice A rationale
Using correction tape is inappropriate as it obscures the original entry, violating the principle of maintaining a clear and accurate audit trail. This makes it impossible to determine what the original error was and who made it, which is crucial for accountability and legal purposes in healthcare documentation.
Choice B rationale
Shredding the original forms and rewriting them is unacceptable because it completely eliminates the original record. This action could be interpreted as an attempt to conceal errors or misrepresent information, which carries significant legal and ethical implications in patient care documentation.
Choice C rationale
Blacking out the error with a thick marker obscures the original information, making it impossible to review the mistake and understand the context. This method does not allow for verification of the initial entry or tracking of the correction process, which is essential for maintaining accurate medical records.
Choice D rationale
Drawing a single line through the incorrect information, making the correction clearly beside it, and then initialing and dating the change maintains the integrity of the original record while indicating who made the correction and when. This method ensures transparency and accountability in documentation, adhering to legal and professional standards for error correction in medical charts.
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