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 ["A","B"]

Explanation

A. Repeat the details of the prescription back to the provider: Verbal/telephone orders must be read back to ensure accuracy (known as read-back verification).

B. Record the reason for the call made to the provider and the results of the call in the Nurse’s Notes: Documentation should include:

Why the call was made
Provider’s response and order
Patient’s condition before and after intervention

C. Tell the charge nurse that the provider has prescribed morphine by telephone: While communication with the charge nurse is good practice, it does not replace proper documentation and verification.

D. Refuse to accept the verbal prescription because this is not an emergency: While verbal orders should be limited to emergencies, they can be accepted in certain non-emergency cases, provided read-back verification and documentation are done.

A. "No complaints of pain or discomfort." B. The patient states, "It feels like a knife stabbing me." C. "Lump diminished." D. "Patient's condition much better today than yesterday."

Correct Answer is B

Explanation

thoroughly. The patient may not have verbalized pain but could still be experiencing it.

B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.

C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).

D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

Which of the following is an example of good charting?

Correct Answer is B

Explanation

When discovering subjective data, recognize that they relate to:

What is the major concern when using a computer for documentation?

The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)

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:

Patient health care records are:

Which of the following statements is correct about abbreviations?

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

On what form/forms should the nurse chart when administering a narcotic?