Fundamentals in Nursing II (NURB 240) Exam 1 Study Guide questions with complete solutions

Subjective data -- what the patient says Objective data -- what you observe, such as VS, lab results, and physical assessment findings Assessment -- interpret the subjective and objective data and state the problem or note client progress on the problem (may be in the form of a nursing diagnosis) -Plan -- plan of care to address the problem Correct Answer-What is SOAP charting? Format: (Prohibited abbreviation ) = (Correct term) -U = unit -IU = International Unit -Q.D. (QD, qd, q.d.), Q.O.D. (QOD), qod, q.o.d.) = daily, every other day -Trailing zero (X.0 mg) = never write a zero by itself after decimal point (X mg) -Lack of leading zero (.X mg) = always use a zero before a decimal point (0.X mg) -MS, MSO4, MgSO4 = morphine or magnesium -µg = mcg or microgram -cc = ml for milliliters