CHAPTER 5
A nurse writes in the chart, “Patient slept well throughout the night.” Which documentation standard is not being followed?
Objectivity
A patient says, “No one ever listens to me.” Which nurse reply best demonstrates therapeutic communication?
“Can you tell me more about that?”
Prior to giving a medication that lowers heart rate, which vital sign must the nurse check?
Pulse
Which assessment method involves tapping the body surface to produce sound?
Percussion
The provider orders Amoxicillin 500 mg PO. The medication available is Amoxicillin 250 mg per tablet. How many tablets should the nurse administer?
2 tablets
(500 mg ÷ 250 mg/tab = 2)
A nurse administers a PRN analgesic but does not record it. The next nurse gives another dose. What is the primary cause of this error?
Failure to document
Which nonverbal cue shows the nurse is fully engaged in the conversation?
Leaning toward the patient
A nurse records a temperature of 101.8°F (38.8°C). How should this finding be described in documentation?
Febrile
During abdominal assessment, the nurse notes muscle rigidity. This finding most likely indicates:
Possible underlying inflammation
The provider prescribes Metformin 1,000 mg PO. The pharmacy supplies Metformin 500 mg tablets. How many tablets should be given?
2 tablets
(1000 mg ÷ 500 mg/tab = 2)
Which chart entry reflects factual and objective documentation?
A. “Patient appears nervous.”
B. “Patient states pain is 8 out of 10.”
C. “Patient is being dramatic.”
D. “Patient exaggerates discomfort.”
B. “Patient states pain is 8 out of 10.”
A critical lab value must be reported to the provider. Which method ensures clear and professional communication?
Calling the provider using SBAR
A respiratory rate of 28 breaths per minute should be charted as:
Tachypnea
Bluish discoloration of a patient’s lips should be documented as:
Cyanosis
An order reads: Acetaminophen 650 mg PO. The medication label indicates 325 mg per tablet. How many tablets should the nurse administer?
2 tablets
(650 mg ÷ 325 mg/tab = 2)
When using an electronic health record, which nursing action demonstrates proper documentation practice?
Signing out after charting
After asking a question, the patient remains silent. What is the most appropriate nursing response?
Give the patient time to respond
Which temperature site provides the least reliable reading in a patient with decreased peripheral circulation?
Axillary
When beginning a head-to-toe assessment, which action should the nurse perform first?
Observe the patient’s overall appearance
The healthcare provider orders Digoxin 0.25 mg PO. The medication available is Digoxin 0.125 mg tablets. How many tablets should the nurse give?
2 tablets
(0.25 mg ÷ 0.125 mg/tab = 2)
What patient event should be documented immediately?
A sudden change in vital signs
Which situation requires the nurse to obtain a trained medical interpreter?
The patient speaks a different primary language
While assessing an apical pulse, the nurse notes an irregular rhythm. What should the nurse do next?
Continue counting for a full minute
Crackling sounds heard in the lung bases during assessment most commonly suggest:
Fluid accumulation in the lungs
The provider orders Furosemide 40 mg PO. The medication on hand is Furosemide 20 mg tablets. How many tablets should the nurse administer?
2 tablets
(40 mg ÷ 20 mg/tab = 2)