Which chart entry represents appropriate documentation about the patient's pain assessment?

The patient is sleeping comfortably.

The patient rated the pain at 2 on a 0-to-10 scale.

The patient appears not to be in any pain.

The patient always complains about being in pain.

Answer and Explanation

The Correct Answer is B

Choice A rationale

"The patient is sleeping comfortably" is a subjective observation and does not provide a quantifiable measure of the patient's pain level. While comfort is important, this statement lacks specific information about the patient's pain experience and does not allow for consistent monitoring or evaluation of pain management interventions.

Choice B rationale

"The patient rated the pain at 2 on a 0-to-10 scale" is an example of appropriate pain assessment documentation. It uses a standardized pain scale, allowing the patient to quantify their pain intensity. This provides objective data that can be used to monitor changes in pain levels over time and evaluate the effectiveness of pain management strategies.

Choice C rationale

"The patient appears not to be in any pain" is a subjective interpretation by the nurse based on observation. It does not involve input from the patient about their pain experience. Pain is subjective, and a patient may be experiencing pain even if they do not outwardly appear to be in distress. Relying solely on observation can lead to underreporting and undertreatment of pain.

Choice D rationale

"The patient always complains about being in pain" is a generalization and does not provide specific information about the patient's current pain level. It can also introduce bias into future pain assessments. Each pain report should be documented objectively and based on the patient's current experience, not past complaints.

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Correct Answer is ["2120"]

Explanation

Step 1: Convert ounces of popsicle to milliliters. 1 oz is approximately 30 mL, so 8 oz × 30 mL/oz = 240 mL.

Step 2: Total oral intake is the sum of popsicle and ice chips. 240 mL + 80 mL = 320 mL.

Step 3: Intravenous fluid intake is the infusion rate multiplied by the duration of the shift. The shift is 12 hours (6 AM to 6 PM), so 150 mL/hr × 12 hr = 1800 mL.

Step 4: Total intake is the sum of oral and intravenous intake. 320 mL + 1800 mL = 2120 mL.

Final Answer: 2120 mL.

A. The nurse manager sets unit policies, conducts annual reviews, and disciplines the staff as needed. B. The nurse manager makes rounds on the unit every day to monitor for problems with patient care. C. The staff nurses work with the manager to review care options to prevent surgical site infections. D. The nurse manager conducts regular staff meetings to provide updates about new equipment and agency policies.

Correct Answer is C

Explanation

Choice A rationale

Centralized management involves top-down decision-making, where the nurse manager holds authority for policies, reviews, and disciplinary actions. This structure concentrates power and control at the managerial level, limiting staff input and autonomy in shaping unit operations and standards of practice.

Choice B rationale

Regularly monitoring patient care by making rounds is a supervisory function, ensuring adherence to established protocols and identifying immediate issues. While important for quality assurance, it doesn't inherently decentralize decision-making or empower staff in a collaborative manner.

Choice C rationale

Decentralized management empowers staff at lower levels to participate in decision-making processes. When staff nurses collaborate with the manager to review care options and implement preventive strategies, it distributes authority and fosters a sense of ownership and shared responsibility for patient outcomes.

Choice D rationale

Conducting regular staff meetings to disseminate information about new equipment and policies is a communication strategy that ensures staff are informed. However, it does not necessarily involve staff in the formulation or decision-making processes related to these changes, maintaining a more centralized approach.

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Which chart entry represents appropriate documentation about the patient's pain assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Calculate the intake for the 6 AM to 6 PM shift. A patient consumes 8 oz of a popsicle and 80 mL of ice chips during the shift. Intravenous fluids infused at 150 mL/hr during the shift. The Foley catheter was emptied of 800 mL at 1 AM & 925 mL at 6 PM. 80 mL were emptied from a drain at 6 PM.

Correct Answer is ["2120"]

Explanation

Which nursing leadership approach demonstrates decentralized management?

Correct Answer is C

Explanation

Fluid volume deficit related to:

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