The nurse documents in the patient record, "0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.” The most significant statement about the documentation is that it is:
unacceptable because it is vague subjective data without supportive data
good because it shows immediate response to the problem
inadequate because the time of physician notification is not listed
acceptable because it includes assessment, intervention and evaluation
The Correct Answer is D
A. Unacceptable because it is vague subjective data without supportive data: The documentation includes objective data (BP, pulse), a physician notification, an intervention (analgesic), and an outcome.
B. Good because it shows immediate response to the problem: While the response to the problem is immediate, this choice is incomplete as it does not acknowledge that the documentation reflects all aspects of assessment, intervention, and evaluation.
C. Inadequate because the time of physician notification is not listed: While including the exact time of physician notification is best practice, the record still meets documentation standards.
D. Acceptable because it includes assessment, intervention, and evaluation: The note follows the nursing process (assessment, intervention, and response/evaluation), making it acceptable documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Signs of fluid overload: Fluid overload presents with edema, crackles in lungs, and increased blood pressure, not dry skin and mucous membranes.
B. Symptoms: Symptoms are subjective (e.g., pain, nausea), while the given findings are observable signs.
C. Data clustering: The nurse groups related signs (flushed skin, dry mucous membranes, elevated temperature) to identify a pattern suggesting dehydration or fever.
D. Urinary retention: Urinary retention is associated with bladder distention and reduced urine output, not dry skin and mucous membranes.
Correct Answer is A
Explanation
A. The provider’s observed data: Objective data includes what the nurse or provider directly observes and measures, such as vital signs, lab results, and physical exam findings.
B. All of the answers are correct: Only option A is correct because C and D do not define objective data.
C. The patient’s perception of provided data: The patient’s perception is subjective data, not objective.
D. The patient’s request for information: A request for information is neither assessment data nor an objective finding.
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