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WorksheetsNCM 103 Lec Seatwork #2
Total questions: 15
Worksheet time: 8mins
Which abbreviation in documentation indicates assessment findings rather than interventions?
I&O
SOAP
PRN
NPO
A nurse documents: Patient c/o SOB and CP. Which interpretation is correct?
Complains of shortness of breath and chest pain
Consciousness oriented and stable
Shortness of breathing with cold perspiration
Chronic obstructive breathing with cardiac problem
A postoperative patient has an order for NPO. What nursing action is appropriate?
Encourage oral fluids
Provide ice chips
Withhold food and fluids
Administer clear liquids only
Which abbreviation correctly documents urinary output monitoring?
ADLs
I&O
ROM
VS
A nurse charts: VS stable, afebrile. Which vital sign supports this documentation?
BP 150/90 mmHg
HR 110 bpm
Temp 36.8°C
RR 28/min
Which abbreviation refers to a legal medical record entry method commonly used by nurses?
PRN
SOAP
STAT
NGT
Which abbreviation documents a patient’s ability to perform self-care activities?
ADLs
LOC
ROM
GCS
A nurse documents: Patient AO x3. What does this indicate?
Alert and oriented to person, place, and time
Alert only
Oriented to place only
Awake and oxygenated
Which abbreviation best describes neurological status in nursing assessment?
ROM
GCS
I&O
BMI
Which documentation entry best reflects objective data?
Patient states pain is 8/10
Patient feels dizzy
BP 120/80 mmHg
Patient reports nausea
Which documentation entry places the nurse at greatest legal risk?
“Patient reports pain 7/10; morphine administered as ordered.”
“Physician notified of hypotension at 1430.”
“Patient appears intoxicated and rude.”
“Dressing dry and intact.”
A nurse documents: “BP taken late due to heavy workload.” Why is this entry inappropriate?
Uses incorrect abbreviation
Shifts responsibility to staffing issues
Lacks a time entry
Violates patient confidentiality
A nurse writes: “Incision looks infected.” What is the best legally sound revision?
“Incision severely infected.”
“Incision red and swollen.”
“Incision appears bad.”
“Incision questionable.”
Which documentation entry demonstrates proper use of time-sequenced charting?
“Medication given.”
“Patient improved.”
“0800: BP 90/60; 0810: MD notified; 0830: IVF started.”
“Vitals monitored closely.”
Which statement best reflects professional nursing documentation?
“Patient uncooperative and difficult.”
“Patient refuses care frequently.”
“Patient declined bath despite education on hygiene benefits.”
“Patient noncompliant.”
