Nursing Elites

1. Which entry in the medical record best meets the requirement for problem-oriented charting?

• A. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV."?
• B. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."?
• C. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV."?
• D. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"?

Correct answer: B

Rationale: Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The correct answer demonstrates problem-oriented charting by following this structure. Choice A, C, and D do not follow the problem-oriented charting format and instead offer examples of different documentation styles such as PIE charting, focus documentation, and narrative documentation, respectively. Therefore, choice B is the best example of problem-oriented charting among the options provided.

2. The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician?

• A. Assess the patient for decreased level of consciousness
• B. Administer Normal Saline
• C. Insert an NG Tube
• D. Connect and read an EKG

Correct answer: B

Rationale: The patient is entering neurogenic shock due to the spinal cord injury, leading to hypotension and bradycardia. Administering Normal Saline is essential to replace fluid volume, which can help in treating the hypotension and bradycardia symptomatically. This intervention aims to stabilize the patient's cardiovascular status. Assessing for decreased level of consciousness (Choice A) may be important but addressing the hemodynamic instability takes precedence. Inserting an NG Tube (Choice C) and connecting and reading an EKG (Choice D) are not the immediate actions required for the presenting symptoms of hypotension and bradycardia.

3. What is the most common complication of chest wall injury?

• A. Hemothorax
• B. Atelectasis
• C. Pneumonia
• D. Pneumothorax

Correct answer: C

Rationale: Pneumonia is the most common complication of chest wall injury. Chest wall trauma can lead to impaired lung function, making patients more susceptible to pneumonia due to reduced ability to clear secretions and impaired breathing. While hemothorax and pneumothorax are potential complications of chest wall injury, pneumonia is more commonly encountered. Atelectasis, although a common pulmonary complication, is not typically the most common complication seen in chest wall injuries.

4. A patient is found unconscious in their room with rhythmic jerking of all four extremities and heavy foaming at the mouth. The patient was on seizure precautions with bedrails up and padded. What is the priority action for the nurse to take?

• A. Administer Lorazepam (Ativan)
• B. Turn the patient to his/her side
• C. Call the physician
• D. Suction the patient

Correct answer: B

Rationale: The nurse's priority action should be to turn the patient to his/her side. This position helps maintain an open airway and prevents aspiration of secretions or vomitus. Administering Lorazepam (Ativan) without ensuring a clear airway could lead to further complications. Calling the physician is important, but immediate interventions to protect the airway take precedence. Suctioning the patient may be necessary but should not be the initial action; positioning for airway protection is the priority.

5. A client is in the post-anesthesia care unit (PACU) shivering despite being covered with several layers of blankets. What is the nurse's next action?

• A. Turn the client to the prone position
• B. Assist the client in breathing deeply
• C. Administer meperidine as ordered
• D. None of the above

Correct answer: C

Rationale: In the post-anesthesia care unit, clients may experience shivering or chills due to a drop in body temperature after surgery. Meperidine (Demerol) can be prescribed to alleviate shivering in cold clients. The prone position (lying face down) and deep breathing exercises are not interventions specifically indicated for addressing shivering due to low body temperature. Therefore, administering meperidine as ordered is the most appropriate action to manage the client's shivering in this scenario.

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