Reading Patient Charts Flashcards

A nurse is reviewing the following entry in a patient's chart: 'Pt. c/o sharp, stabbing pain to RUQ, rated 8/10. Skin is diaphoretic and clammy. V/S: BP 150/90, HR 110, RR 22, T 37.8 C. NPO since midnight. Awaiting ultrasound.' Which of the following is the most accurate summary of the patient's condition?

Answer: The patient is experiencing significant pain and showing signs of distress, requiring further investigation.

The correct answer accurately synthesizes all the key information. The patient's complaint ('c/o') of 'sharp, stabbing pain' rated 8/10 indicates severe pain, not minor discomfort. The vital signs (V/S) are elevated (hypertension, tachycardia, tachypnea), and the skin is 'diaphoretic and clammy,' which are signs of distress. The patient is being kept 'NPO' (nothing by mouth) and is 'awaiting ultrasound,' which points to the need for further diagnostic investigation.

The physician's orders in a patient's chart state: 'Administer Gravol 50 mg IM q6h PRN for N/V.' How should the nurse interpret this order?

Answer: Administer 50 mg of Gravol into the muscle every 6 hours only if the patient complains of nausea or vomiting.

This answer correctly decodes all the abbreviations. 'IM' stands for intramuscular (into the muscle). 'q6h' means every 6 hours. 'PRN' means 'pro re nata' or as needed. 'N/V' stands for nausea and vomiting. Therefore, the nurse should give the medication via injection into the muscle, only when the patient experiences nausea or vomiting, and no more frequently than every 6 hours.

While reviewing a new admission's chart, the nurse notes the following: 'Allergies: NKDA'. What does this abbreviation signify?

Answer: No Known Drug Allergies

'NKDA' is a standard medical abbreviation used in patient charts to indicate 'No Known Drug Allergies'. This is a critical piece of information for safe medication administration.

A nurse reads the following progress note for a post-operative patient: 'Day 2 post-op R TKR. Pt ambulated 10m with 2x assist. Incision C/D/I, no erythema or purulent drainage noted. States pain managed with PO analgesia. Voiding qs. A/O x 3.' Which of the following indicates the patient is progressing as expected?

Answer: The clean, dry, and intact incision site.

The note 'Incision C/D/I' stands for Clean, Dry, and Intact. The absence of 'erythema' (redness) or 'purulent drainage' (pus) are positive signs that the surgical wound from the Right Total Knee Replacement (R TKR) is healing properly without signs of infection. Ambulation with assistance is expected on day 2 post-op, and pain managed with oral ('PO') medication is a good sign.

A patient's lab results section shows: 'Hgb 95 g/L'. The normal range for an adult male is 135-175 g/L. Based on this result, which of the following conditions should the nurse be most concerned about?

Answer: Anemia

Hgb stands for Hemoglobin. A result of 95 g/L is significantly below the normal range of 135-175 g/L for an adult male. Low hemoglobin is the primary indicator of anemia, a condition characterized by a deficiency of red blood cells or hemoglobin in the blood.

You are reviewing a patient's medication administration record (MAR). Which of the following entries requires immediate clarification from the prescriber?

Answer: Digoxin .125 mg PO daily. Hold for HR < 60.

The order 'Digoxin .125 mg PO daily. Hold for HR < 60.' contains a trailing zero and a leading decimal, which are on the 'Do Not Use' list of abbreviations by organizations like ISMP Canada to prevent medication errors. The correct way to write this is 'Digoxin 0.125 mg...'. The period before the number could be missed, leading to an overdose. The other orders use standard and safe abbreviations.