CELBAN Reading Patient Charts 3 — Questions and Answers
Question 1: A chart order reads: 'Discontinue IV access if tolerating PO fluids.' When should the nurse remove the IV?
- As soon as the IV fluids run out
- Once the patient can drink and swallow fluids without difficulty (Correct answer)
- After 24 hours have passed since the last IV dose
- When the patient requests oral fluids
Correct 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.
Question 2: A patient's chart allergy section lists: 'PCN — Anaphylaxis.' Which antibiotic should the nurse question before administration?
- Azithromycin
- Vancomycin
- Ampicillin (Correct answer)
- Ciprofloxacin
Correct answer: Ampicillin
Ampicillin is a penicillin-class antibiotic (PCN), and administering it to a patient with a documented PCN anaphylaxis allergy would be dangerous.
Question 3: A nursing note states: 'Pt. A&O x 3.' What does this assessment finding indicate?
- The patient is alert and oriented to person, place, and time (Correct answer)
- The patient has been assessed three separate times today
- The patient is ambulatory and oxygen-dependent for three hours
- The patient is alert and has three active medical diagnoses
Correct 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).
Question 4: A chart notation reads: 'PRN Acetaminophen 650 mg PO q4-6h for pain rated >4/10.' When should the nurse administer this medication?
- Every 4 to 6 hours regardless of pain level
- Only when the patient reports pain at a score greater than 4 out of 10 (Correct answer)
- Every 4 hours when the patient reports any pain
- Only at bedtime when pain is at its worst
Correct 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.
Question 5: The physician's order in a chart reads: 'Elevate HOB 30 degrees.' What does HOB stand for?
- Heart of Bed
- Head of Bed (Correct answer)
- Height of Body
- Horizontal of Baseline
Correct 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.
Question 6: A patient's chart shows a Glasgow Coma Scale (GCS) score of 8. How should the nurse interpret this finding?
- The patient is fully conscious and oriented
- The patient has a mild cognitive impairment
- The patient has a severe brain injury requiring immediate airway management consideration (Correct answer)
- The patient is mildly confused but stable
Correct 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.
Question 7: A nursing note documents: 'Skin turgor poor, mucous membranes dry, urine dark amber.' Which nursing diagnosis is most supported by these chart findings?
- Risk for infection
- Deficient fluid volume (Correct answer)
- Impaired skin integrity
- Ineffective tissue perfusion
Correct 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.
CELBAN Reading Patient Charts 3
A chart order reads: 'Discontinue IV access if tolerating PO fluids.' When should the nurse remove the IV?