Reading Patient Charts Flashcards
7 cards from real CELBAN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Reading Patient Charts flashcards as text
A chart order reads: 'Discontinue IV access if tolerating PO fluids.' When should the nurse remove the IV?
Answer: Once the patient can drink and swallow fluids without difficulty
'Tolerating PO fluids' means the patient can drink and swallow oral fluids without nausea, vomiting, or difficulty.
A patient's chart allergy section lists: 'PCN — Anaphylaxis.' Which antibiotic should the nurse question before administration?
Answer: Ampicillin
Ampicillin is a penicillin-class antibiotic (PCN), and administering it to a patient with a documented PCN anaphylaxis allergy would be dangerous.
A nursing note states: 'Pt. A&O x 3.' What does this assessment finding indicate?
Answer: The patient is alert and oriented to person, place, and time
A&O x 3 means alert and oriented to three domains: person (who they are), place (where they are), and time (date/day).
A chart notation reads: 'PRN Acetaminophen 650 mg PO q4-6h for pain rated >4/10.' When should the nurse administer this medication?
Answer: Only when the patient reports pain at a score greater than 4 out of 10
PRN means 'as needed' and the condition specified is pain rated greater than 4 on a 10-point scale.
The physician's order in a chart reads: 'Elevate HOB 30 degrees.' What does HOB stand for?
Answer: Head of Bed
HOB is a standard nursing abbreviation for Head of Bed, and elevating it 30 degrees is commonly ordered to prevent aspiration and reduce ICP.
A patient's chart shows a Glasgow Coma Scale (GCS) score of 8. How should the nurse interpret this finding?
Answer: The patient has a severe brain injury requiring immediate airway management consideration
A GCS score of 8 or below indicates severe brain injury and is the threshold at which airway management (intubation) is typically considered.
A nursing note documents: 'Skin turgor poor, mucous membranes dry, urine dark amber.' Which nursing diagnosis is most supported by these chart findings?
Answer: Deficient fluid volume
Poor skin turgor, dry mucous membranes, and dark concentrated urine are classic signs of dehydration, supporting a nursing diagnosis of deficient fluid volume.