Data Collection and Reporting
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Objective data is any information that is fact. This means that the information is unbiased and multiple people should be able to interpret the information in the same way. All of the following are an example of objective data except for:
The patient weighs 160 pounds.
The patient has been hospitalized for 3 days.
The patient's temperature is 100.3F.
The patient's pain level is 3 out of 10.
The patient has a bed sore.
Question 1 Explanation:
Subjective data is any information drawn from the patient's thoughts or feelings. This includes the patient's pain level.
A patient's chart is a legal document. If something is mistakenly written on the chart, the correct action is to:
Draw a single line through the incorrect information with blue or black ink. Write "Error," explain the reason for the error, and write your initials.
Use correction ink so the page looks neat and then write in the correction information with black or blue ink. Also write your initials.
Scratch out the error with red ink, explain the reason for the error, write in the correct information, and write your initials.
Get a new chart and re-write all the correct information in any ink color as long as it's consistent.
Charting is an accurate record of the patient's medical care while in hospital (including therapies given, treatments performed, and the patient's progress). Information typically included in the chart include all of the follow except:
Names of visitors
Intakes and outputs
Charting by exception is:
Without a template so the nurse has the ability to tailor the format of their charts to how they feel is most efficient.
Recording your patient's progress only twice a day so that you have more time to provide exceptional care.
Recording the patient's progress based on the Subjective, Objective, Assessments, and Plans headings.
Recording the patient's progress based on the Problem, Intervention, and Evaluation headings.
Having a templated chart with pre-formed assessments that require recorded assessments only when abnormal findings are noted.
When calculating total fluid intake during a 24 hour period, all of the following should be included expect for:
Any liquids per os
Any IV fluids
Any eye or skin ointments that are absorbed
Pudding per os
Any tube feeding
If a patient does not have a bowel movement for more than ______, the patient is considered at an increased risk for developing constipation and the nurse should be notified.
The normal heart rate/pulse rate for an adult human is 60-80 bpm. An elevated heart rate can be expected with:
a decreased body temperature
good physical condition (aka: a patient that is cardiovascularly fit)
increased vagal tone
Orthostatic hypotension is:
When a patient has a low blood pressure due to a larger body size.
When a patient's blood pressure decreases following extreme exertion (such as running a marathon)..
When a patient experiences a decrease in blood pressure due to a change in their position
When a patient with hypertension is given medications that cause their blood pressure to return to normal.
Question 8 Explanation:
To evaluate a patient for orthostatic hypotneesion, take their blood pressure when lying down, sitting, and standing if possible. If the blood pressure decreases >20mmHg systolic, orthostatic hypotension should be suspected.
Possible indications of an abnormal body temperature are:
Low temperature can indicate onset of a new infection
HIgh temperature can indicate infection
High temperature is indicative of Pneumonia
Low temperature is almost always Hypothermia
A and B are correct
Which is not one of the 5 vital signs:
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