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Documentation and Reporting · NCLEX Exam

Which documentation entry is most appropriate after giving a PRN pain medication?

  1. “Pain meds given — patient improved.”
  2. “Administered 5 mg morphine IV at 1400; patient’s pain decreased from 8/10 to 3/10 at 1430; vital signs stable.”
  3. “Pain meds given as ordered; no further issues.”
  4. “Patient asked for relief; gave medication.”
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Correct answer: “Administered 5 mg morphine IV at 1400; patient’s pain decreased from 8/10 to 3/10 at 1430; vital signs stable.”

Good documentation includes objective details: what, when, response, and vital signs.

Difficulty: Easy Question 2 of 20

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