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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Evaluation, planning, assessment, implementation: Evaluation is the last step, not the first.

B. Assessment, planning, implementation, evaluation
The correct order of the nursing process is:

Assessment – Gather data
Planning – Develop goals and interventions
Implementation – Carry out the plan
Evaluation – Determine effectiveness and adjust as needed

C. Implementation, assessment, planning, evaluation: Assessment must come first before implementing any plan.

D. Planning, evaluation, assessment, implementation: Planning comes after assessment, and evaluation is last, not second.

A. the insulin was administered based per the nurse's testimony B. none of the answers are correct C. the insulin was administered based on the witness testimony D. the insulin was not administered because it was not charted

Correct Answer is D

Explanation

A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.

B. None of the answers are correct: One of the answers is correct based on legal documentation principles.

C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.

D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select the proper order of the phases of the Nursing Process:

Correct Answer is B

Explanation

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

Correct Answer is D

Explanation

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

To what does objective data refer when assessing a patient?

Which part of the medical record can be used as evidence in court?

Which of the following assists the nurse in the identification of nursing diagnoses?

One benefit of computerized charting is that:

The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:

The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an: