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 patient's lab results in the chart show: 'K+ 2.9 mEq/L.' What clinical manifestation should the nurse monitor for given this result?
Answer: Muscle weakness and cardiac arrhythmias
A potassium level of 2.9 mEq/L indicates hypokalemia, which can cause muscle weakness, cramping, and life-threatening cardiac dysrhythmias.
A chart entry reads: 'PT/INR: 3.8. Patient on warfarin.' What action should the nurse anticipate?
Answer: Notify the physician as the INR is above the typical therapeutic range of 2.0–3.0
An INR of 3.8 is above the typical therapeutic range of 2.0–3.0 for most indications, increasing the patient's risk of bleeding and requiring physician notification.
A transfer summary chart notes: 'Pt. transferred from ICU, weaned off vasopressors 12h ago, hemodynamically stable.' What does 'hemodynamically stable' mean?
Answer: The patient's blood pressure and cardiac output are adequate without medication support
Hemodynamically stable means the patient's circulation — blood pressure, heart rate, and cardiac output — is maintaining adequate perfusion without requiring vasopressor support.
A chart shows the following order: 'Ambulate TID with assistance, fall precautions in place.' What does TID mean?
Answer: Three times daily
TID is the Latin abbreviation for 'ter in die,' meaning three times per day.
A patient's chart documents a pain score of 7/10 at 0800 and the nurse administered morphine 2 mg IV at 0810. The follow-up note at 0840 reads: 'Pain 3/10, tolerating well.' What does this charting demonstrate?
Answer: Proper documentation of medication administration and reassessment of effectiveness
Documenting the baseline pain score, medication given with dose/route/time, and a follow-up reassessment demonstrates proper pain management documentation practices.
A patient's chart contains a DNR order. What does this order direct nursing staff to do?
Answer: Do not perform cardiopulmonary resuscitation if the patient's heart or breathing stops
A DNR (Do Not Resuscitate) order instructs healthcare providers not to perform CPR in the event of cardiac or respiratory arrest.
A chart progress note reads: 'Crackles auscultated bilaterally at lung bases, O2 sat 91% on 2L NC.' What should the nurse do first?
Answer: Increase oxygen flow rate and reassess oxygen saturation
An O2 saturation of 91% is below the acceptable threshold of 95%; increasing the oxygen delivery and reassessing is the immediate nursing action.