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NCLEX PN Mastery Q - Documentation

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80 views1 page

NCLEX PN Mastery Q - Documentation

Uploaded by

tolman3904
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NCLEX PN Mastery

Hematology & Immunology 10

Back To Med/Surg SHARE

MAR Progress Note Flow Sheet

CAD Correct
Nurses Note ANSWERED 1614 TIMES
40% CORRECT
0800: Assumed care of the client. Client alert,
awake, and oriented to person and situation but
VIEW QUESTION
is confused to time and place. Skin warm, pink,
dry. Petechiae noted to bilateral arms, skin intact.
ARespirations
nurse caresare
for regular
a client and
withnon-labored.
a hematological
Fine
disorder. After assuming
crackles auscultated care and
bilateral performing
lower lobes, an
otherwise clear throughout. SpO2 96% room air
View
via Exhibits
cont. pulse ox. HR reg without murmur. +2
pulses upper and lower extremities. The client
reports mild discomfort; Pain scale 3/10.
19% The nursing notes should include the plan
of care.
The nursing notes section does not include the
plan of care. Rather, the plan of care is outlined
separately and is a fluid document that changes
frequently.
The plan of care is typically formatted according
to the nursing process (assessment, diagnosis,
plan, intervention, evaluation).

18% The assessment is not complete based on


the client’s symptoms.
The nurse correctly documented the assessment
and used a narrative format. This type of
documentation is acceptable and represents a
properly documented assessment.

22% Medication is administered that is


contraindicated.
There is no indication in the exhibit to show that a
medication was administered that would be
contraindicated for this client.

41% The assessment is recorded but not any


interventions.
The nursing notes should include the
interventions performed based on the
assessment findings.
The exhibit has a recorded client assessment but
no interventions based on this assessment (for
example: placed call light within reach; bed
placed in low position; encouraged client to deep
breathe and cough).

Key Takeaway
Nursing notes include client assessment and
interventions.

Explanation
Nursing Notes

Must include assessment and


interventions based on assessment
findings
May be in narrative format or an
alternative format depending on the
organization’s documentation system and
policies

Plan of Care

Separate from nursing notes


Changes frequently based on the client’s
progress towards established goals

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7 Comments Sort by Most Popular

Discuss this question

Assessment is incomplete because meds


were administered for pain but no pain was
noted in the assessment.
Reply Hide 1 Reply 9

My Nursing Mastery

Hello, Be sure to read the information


provided carefully. The pain medication
administered was given at 0530. The
assessment was performed at 0800. Nurse
Barb
7

grace

I also thought assessment was incomplete


because I didn't see mention of pain
assessment at 8 (to determine if pain meds
were necessary)
Reply 5

Heather

I thought if they had a hematological


disorder depending on the disorder the
motrin med order needs verified prior to
administration for contraindications.
Reply Hide 1 Reply 2

My Nursing Mastery

Heather, It would be dependent on the


disorder and there is no indication in this item
that it is contraindicated. The key here is that
the nurse has not documented any of the
performed interventions. Nurse Barb
2

Katie

This is an awful question. A nurse is never


going to write a random note, especially
one that encompasses her entire day.
That’s what EPIC and other facility systems
are for. Joint Commission isn’t going to look
for all of that info in a nursing note.
Reply Hide 1 Reply 1

My Nursing Mastery

Surprisingly, some facilities do not use


programs like EPIC. Many are required to
make nursing notes and summaries for the
day. Inpatient hospice facilities require notes
such as these to receive their reimbursement.
Some still do not have electronic medication
administration systems. I know it is frustrating
to see such a wide variety of systems and
requirements across institutions, populations,
and settings! -Nurse Cat
2

Don't Know Somewhat Know Know

NCLEX Prep Library Resources Performance

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