When documenting events in a patient's chart, the nurse should chart:
the specific time of all sudden changes in the patient's condition
the period the shift covers
every 2 hours
every hour on the hour
The Correct Answer is A
A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.
B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.
C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.
D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Validated data: While accurate data is crucial, validated data alone does not form a nursing diagnosis.
B. Data clustering: Data clustering involves grouping related signs, symptoms, and risk factors to determine patterns that lead to a nursing diagnosis.
C. Subjective data: Subjective data (e.g., pain, nausea) is part of assessment but must be combined with objective data to establish a diagnosis.
D. Objective data: Objective data (e.g., lab results, physical exam findings) is important, but a nursing diagnosis requires a comprehensive approach, including data clustering.
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:
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Assessment – Gather data
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Planning – Develop goals and interventions
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Implementation – Carry out the plan
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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.
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