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N201 Review for N314

QuestionAnswer
In what order should events be documented? sequential
Should opinions be included in nursing documentation? no
When should a nursing action be documented? -never before completed -ASAP
clinical judgement opinion or conclusion after analyzing information
a.c. before food
a.m. before noon
amb ambulatory
Abd. abdomen
ad lib. as much as desired
AMA against medical advice
b.i.d. twice daily
BP blood pressure
BM bowel movement
c. with
cap. capsule
c/o complaint of
CTA clear to auscultation
Dx diagnosis
DNR do not resuscitate
fx fracture
gtt. or guttae drops
GI gastrointestinal
GU genitourinary
HA headache
h/o history of
HPI history of present illness
HOB head of bed
Hx history
i.c. between meals
IM intramuscular
inf infusion
inj injection
IV intravenous
I/O intake and output
KVO keep vein open
MDI metered dose inhaler
n. or nocte at night
NKA no know allergies
n/v nausea and vomiting
Neg negative
NG nasogastric
NPO nothing by mouth
NS normal saline
O2 oxygen
p.c. after food
pm afternoon
p.r.n. when required
PE physical exam
PMH past medical history
Pt patient
PT physical therapy
q.i.d. four times daily
q12h every 12 hours
q4h every 4 hours
q6h every 6 hours
Rx take
r/o rule out
ROS review of systems
ROM range of motion
SL sublingual
stat. immediately
SOB shortness of breath
Sx symptoms
s/s signs and symptoms
t.i.d. three times daily
Tx treatment
VS vital signs
Created by: mbaldwin13
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