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 chart shows 'NPO after midnight.' What does this instruction mean for the nursing staff?
Answer: The patient must not eat or drink anything after midnight
NPO stands for 'nil per os' (nothing by mouth), meaning the patient must not consume anything orally after midnight.
A chart entry reads: 'Pt. c/o dyspnea on exertion x 3 days.' Which of the following best interprets this note?
Answer: The patient complains of difficulty breathing during physical activity for three days
C/o means 'complains of,' dyspnea means difficulty breathing, and 'on exertion' indicates it occurs during physical activity.
In a patient's chart, the vital signs section reads: 'BP 90/60 mmHg, HR 118 bpm, RR 24, Temp 38.9°C.' Which finding is most immediately concerning?
Answer: The combination of all four abnormal findings
All four findings together suggest possible septic shock: hypotension, tachycardia, tachypnea, and fever are classic signs requiring immediate intervention.
A nurse reads in a patient's progress note: 'Wound site shows erythema, warmth, and purulent discharge.' What condition does this describe?
Answer: A wound infection
Erythema (redness), warmth, and purulent (pus-containing) discharge are classic signs of a wound infection.
A chart reads: 'Hx of HTN, DM Type 2, and CKD Stage 3.' What does this mean about the patient's medical background?
Answer: History of hypertension, diabetes mellitus type 2, and chronic kidney disease stage 3
Hx = history, HTN = hypertension, DM = diabetes mellitus, CKD = chronic kidney disease.
A medication administration record (MAR) lists: 'Metoprolol 25 mg PO BID.' How should this medication be administered?
Answer: 25 mg by mouth twice daily
PO means 'per os' (by mouth) and BID means 'bis in die' (twice a day).
A nurse reviews a patient's fluid balance chart showing: 'I&O: 1,850 mL / 650 mL.' What should the nurse report to the physician?
Answer: The patient has a significant positive fluid balance suggesting fluid retention
A difference of 1,200 mL between intake (1,850 mL) and output (650 mL) represents a significant positive fluid balance that may indicate fluid retention.