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Comprehensive Nursing Care Revised 2nd Edition Ramont Niedringhaus Test Bank

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Comprehensive Nursing Care Revised 2nd Edition Ramont Niedringhaus Test Bank

ISBN-13: 978-0132560269

ISBN-10: 0132560267

 

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Comprehensive Nursing Care Revised 2nd Edition Ramont Niedringhaus Test Bank

ISBN-13: 978-0132560269

ISBN-10: 0132560267

 

 

 

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Free Nursing Test Questions:

 

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Chapter 14

Question 1

Type: MCSA

The nurse’s responsibility(ies) in client charting include(s)

  1. Ethical obligations
  2. Legal obligations
  3. Legal and ethical obligations
  4. Educational obligation

Correct Answer: 3

Rationale 1: Ethical obligations include respecting human dignity, client privacy and client needs. only obligation.

Rationale 2: Legal obligations include accurate and timely recording, and maintaining client privacy. only obligation.

Rationale 3: Ethical obligations include respecting human dignity, client privacy and client needs. Legal obligations include accurate and timely recording, and maintaining client privacy.

Rationale 4: Educational obligations are not the nurses’ main responsibility in documenting client care and progress.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 2

Type: MCMA

The nurse documents client care, remembering that the following guidelines must be followed:

Standard Text: Select all that apply.

  1. Each entry must be dated and timed per agency policy
  2. Record care before it is provided per agency policy
  3. Make all entries in blue or black ink
  4. Use only accepted abbreviations and symbols
  5. Spell medication names correctly to avoid medication errors

Correct Answer: 1,3,4,5

Rationale 1: Each entry needs to include the date and time the note is written, and needs to be made as soon as possible after performing a nursing action.

Rationale 2: Recording care before it is provided is unethical and illegal.

Rationale 3: Use only blue or black indelible ink per agency policy.

Rationale 4: Use only abbreviations that are approved by the agency; if in doubt spell the word out.

Rationale 5: Spelling medication names will decrease the possibility of medication errors.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 3

Type: MCMA

The nurse avoids errors in documentation by following accepted guidelines when documenting in a client record, which include:

Standard Text: Select all that apply.

  1. Describe what you think
  2. Quote client directly
  3. Describe observed behavior
  4. Leave spaces between entries per agency policy
  5. Write error through a mistaken entry

Correct Answer: 2,3

Rationale 1: An accurate entry records what the nurse sees and hears, not thoughts or opinions.

Rationale 2: Quoting client directly will ensure that client’s concerns are recorded correctly.

Rationale 3: Description of observed behavior, such as crying is more accurate than the nurse’s interpretation of what the behavior means, such as anxiety.

Rationale 4: Write on every line, but never between lines. Leaving a space could allow for making a late entry by another person.

Rationale 5: Correct an error by drawing a single line through the error and writing the word error above it.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 4

Type: MCSA

The nurse records care of a client who is medicated for pain. The most accurate entry would be:

Correct Answer: 2

Rationale 1: Assessments, interventions and client responses are recorded in the order in which they occur. Every intervention needs an evaluation to be considered complete

Rationale 2: Assessments, interventions and client responses are recorded in the order in which they occur. Every intervention needs an evaluation to be considered complete. In addition, the nurses recorded the client’s statement.

Rationale 3: Assessments, interventions and client responses are recorded in the order in which they occur. Every intervention needs an evaluation to be considered complete. The initial entry did not include an evaluation of effectiveness.

Rationale 4: Assessments, interventions and client responses are recorded in the order in which they occur. Every intervention needs an evaluation to be considered complete. Site of pain was not included in this entryRemember, another healthcare professional would not know if where the pain originated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 5

Type: MCMA

Accurate, complete, and appropriate nursing entries in a client chart include:

Standard Text: Select all that apply.

  1. (date) 0200 Mrs. Smith appears to be sleeping.——S. Smith, LPN
  2. (date) 0200 Client resting in bed with eyes closed.——S. Smith, LPN
  3. (date) 0800 Client angry at husband for spending too much money. ——-S. Smith, LPN
  4. (date) 0900 Client refused 0400 dose of Amoxacillin.——-S. Smith, LPN
  5. (date) 0700 Client smiling, talking on telephone. —–S. Smith, LPN

Correct Answer: 2,5

Rationale 1: The word ‘appears’ makes the entry an interpretation, rather than an observation.

Rationale 2: This entry describes what the nurse observed.

Rationale 3: This entry interprets the client’s actions or words. A more accurate entry would be: (date) 0800 Client talking on phone with loud voice. Stated “how could you spend the mortgage money on a car?” Client stated that she was talking to her husband.—-S. Smith, LPN.

Rationale 4: This entry is not appropriate as it is five hours after the medication was refused, and does not include “late entry”.

Rationale 5: This entry describes what the nurse observed.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 6

Type: MCSA

When accessing a client’s record, the nursing student is careful to

  1. Use the instructors password
  2. Turn the monitor around when walking away from the computer
  3. Leave notes and information in the facility’s receptacle for papers containing PHI when finished for the day
  4. Allow only the client’s family to see the notes

Correct Answer: 3

Rationale 1: Passwords for electronic medical records should not be shared.

Rationale 2: The student should sign out of the computer when leaving the terminal.

Rationale 3: All material with PHI (protected health information) should be left at the facility, and care plans should only include initials to protect client confidentiality.

Rationale 4: The nurse should not allow access to a client’s record by significant others or any other person other than the healthcare providers who are directly involved in the care of the client.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 7

Type: MCMA

When correcting an incorrect entry, or posting late entry in an electronic medical record the nurse:

Standard Text: Select all that apply.

  1. Indicates the reason for the correction
  2. Identifies the entry as a late entry
  3. Enters the date the entry should have been made
  4. Sign the entry
  5. Document the late entries as soon as possible

Correct Answer: 1,2,5

Rationale 1: The corrected entry should be labeled “wrong patient” or other appropriate terminology.

Rationale 2: Late entries need to be labeled as such.

Rationale 3: Late entries need to be dated with the date the entry is being made.

Rationale 4: The entry needs to be signed per agency protocol.

Rationale 5: Late entries need to be entered as soon as possible; the longer the time lapse, the less reliable the entry becomes.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 8

Type: MCMA

Understanding the nursing process is essential to which of the following types of documentation methods:

Standard Text: Select all that apply.

  1. PIE charting
  2. APIE charting
  3. CORE DAE documentation system
  4. SOAP charting
  5. CBE

Correct Answer: 1,2,3

Rationale 1: PIE charting (problem, intervention, evaluation) is based on the nursing process.

Rationale 2: APIE charting (assessment, problem, intervention, evaluation) is based on the nursing process.

Rationale 3: CORE DAE documentation system focuses on the nursing process; it consists of a database, plans of care, flow sheets, progress notes, discharge summary; DAE stands for data, action, evaluation.

Rationale 4: SOAP charting (subjective data, objective data, assessment, planning) is often oriented around a problem list.

Rationale 5: CBE (charting by exception) is a documentation system in which only significant findings or exceptions to norms are recorded; CBE includes unique flow sheets, documenting by reference to agency’s printed standards of nursing practice; documentation forms at the bedside for immediate recording.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 9

Type: MCSA

The nurse who works in a facility that is changing from a source oriented system of documentation to the FACT system of documentation will discover the main difference between the two is

  1. The FACT system duplicates information
  2. The source oriented system duplicates information
  3. The FACT system documents progress in DAE format
  4. The FACT system is similar to CBE and is designed to eliminate redundant and irrelevant data

Correct Answer: 4

Rationale 1: The FACT system is consists of flow sheets that are individualized, assessment sheet that is standardized, concise integrated progress notes and flow sheets, timely entries, and is computer ready. It is efficient and time saving.

Rationale 2: The source oriented system tends to have duplication of information, as every caregiver makes entries in different parts of the record.

Rationale 3: The FACT system does not use the data, action evaluation format of progress notes.

Rationale 4: The FACT system is named for its elements, and is designed to eliminate redundant and irrelevant data and inconsistencies in recording.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 10

Type: MCMA

The LPN/LVN is giving change of shift report to the oncoming nurse. Report on the client who has just been admitted from the emergency room for an asthma attack should include:

Standard Text: Select all that apply.

  1. Name, age, room number
  2. List of client’s problems
  3. Visitors who have seen client, including clergy
  4. Head to toe review
  5. Medication list

Correct Answer: 1,2,4

Rationale 1: Report on newly admitted clients should include diagnosis, age, general condition, plan of therapy, information about client’s support people.

Rationale 2: A current problem list, including priorities and changes in condition during the shift should be included.

Rationale 3: Coming and going of visitors is not included unless there is a problem or concern.

Rationale 4: Report on newly admitted clients should include diagnosis, age, general condition, plan of therapy, information about client’s support people.

Rationale 5: Current medication list for a new admission will be of interest to make sure continuity is maintained.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 11

Type: MCSA

When explaining the purpose and characteristics of reporting to the new graduate, the nurse summarizes the common features as

  1. Individualized
  2. Concise
  3. Written
  4. SBAR format

Correct Answer: 2

Rationale 1: Reporting may be given to a group of nurses or to the nurse taking over the nurse’s assigned clients.

Rationale 2: A report should be concise, including pertinent information, but should not include any extraneous detail.

Rationale 3: Reporting may be written or oral

Rationale 4: SBAR format (Situation, background, assessment, recommendation) is a format that is useful in many reporting situations, but is not common to all reporting formats

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 12

Type: MCSA

When confirming telephone orders or other communication, the LPN/LVN documents

  1. Telephone order received by
  2. Verbal order received by
  3. Agency protocol
  4. 100% read back

Correct Answer: 4

Rationale 1: Not all telephone communication involves orders; it may involve laboratory information.

Rationale 2: Not all telephone communication involves orders; it may involve laboratory information.

Rationale 3: Agency protocol should concur with regulatory agency policy.

Rationale 4: The Joint Commission requires that any information given over the phone be repeated to the caller and documented as “100% read back.”.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 13

Type: MCMA

The student nurse is attending a nursing care conference. Characteristics of the nursing care conference include:

Standard Text: Select all that apply.

  1. Discuss possible solutions to a client problem
  2. Working together as a group to create a plan of care
  3. Climate of respect
  4. Discussion of nursing unit issues
  5. Listening to others’ idea

Correct Answer: 1,2,3

Rationale 1: The goal of the nursing care conference is to discuss possible solutions to certain client problems.

Rationale 2: Nurses work together as a group to create a plan of care that is consistent.

Rationale 3: Nurses work and communicate with a climate of respect.

Rationale 4: Discussion of other issues on the nursing unit is not appropriate at this time.

Rationale 5: The nurses at a care conference listen to each others’ ideas with an open mind to find a solution for the client problem.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 14

Type: MCMA

The LPN/LVN will often be responsible for completing the discharge note or referral summary. The information to be documented includes:

Standard Text: Select all that apply.

  1. Resolved health problems
  2. Continuing health problems
  3. Treatments that have been completed
  4. Self-care abilities
  5. Current medications

Correct Answer: 1,2,4,5

Rationale 1: Resolved health problems need to be included as part of the database.

Rationale 2: Continuing health problems and care needs must be included for appropriate follow-up care.

Rationale 3: Treatments that are not to be continued are unnecessary to report.

Rationale 4: Self-care and functional abilities including vision, hearing, etc., should be reported to the receiving care facility.

Rationale 5: Current medications need to be included in the report so that important therapies are not interrupted.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 15

Type: MCSA

The nurse’s responsibilities in client charting include:

  1. Ethical obligations.
  2. Legal obligations.
  3. Legal and ethical obligations.
  4. Educational obligations.

Correct Answer: 3

Rationale 1: Ethical obligations include respecting human dignity, client privacy, and client needs. only obligation.

Rationale 2: Legal obligations include accurate and timely recording, and maintaining client privacy. only obligation.

Rationale 3: Ethical obligations include respecting human dignity, client privacy, and client needs. Legal obligations include accurate and timely recording, and maintaining client privacy.

Rationale 4: Educational obligations are not the nurses’ main responsibility in documenting client care and progress.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 16

Type: MCMA

The nurse documents client care, remembering that the following guidelines must be followed:

Standard Text: Select all that apply.

  1. Each entry must be dated and timed per agency policy.
  2. Record care before it is provided per agency policy.
  3. Make all entries in blue or black ink.
  4. Use only accepted abbreviations and symbols.
  5. Spell medication names correctly to avoid medication errors.

Correct Answer: 1,3,4,5

Rationale 1: Each entry needs to include the date and time the note is written, and needs to be made as soon as possible after performing a nursing action.

Rationale 2: Recording care before it is provided is unethical and illegal.

Rationale 3: Use only blue or black indelible ink per agency policy.

Rationale 4: Use only abbreviations that are approved by the agency; if in doubt, spell the word out.

Rationale 5: Spelling medication names will decrease the possibility of medication errors.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 17

Type: MCMA

The nurse avoids errors in documentation by following accepted guidelines when documenting in a client record, which include:

Standard Text: Select all that apply.

  1. Describe what you think.
  2. Quote the client directly.
  3. Describe observed behavior.
  4. Leave spaces between entries per agency policy.
  5. Write through a mistaken entry.

Correct Answer: 2,3

Rationale 1: An accurate entry records what the nurse sees and hears, not thoughts or opinions.

Rationale 2: Quoting the client directly will ensure that the client’s concerns are recorded correctly.

Rationale 3: Description of observed behavior, such as crying, is more accurate than the nurse’s interpretation of what the behavior means, such as anxiety.

Rationale 4: Write on every line, but never between lines. Leaving a space could allow for another person’s making a later entry.

Rationale 5: Correct an error by drawing a single line through the error and writing the word error above it.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 18

Type: MCMA

Accurate, complete, and appropriate nursing entries in a client chart include:

Standard Text: Select all that apply.

  1. (date) 0200 Mrs. Smith appears to be sleeping.——S. Smith, LPN
  2. (date) 0200 Client resting in bed with eyes closed.——S. Smith, LPN
  3. (date) 0800 Client angry at husband for spending too much money. ——-S. Smith, LPN
  4. (date) 0900 Client refused 0400 dose of Amoxicillin.——-S. Smith, LPN
  5. (date) 0700 Client smiling, talking on telephone. —–S. Smith, LPN

Correct Answer: 2,5

Rationale 1: The word ‘appears’ makes the entry an interpretation, rather than an observation.

Rationale 2: This entry describes what the nurse observed.

Rationale 3: This entry interprets the client’s actions or words. A more accurate entry would be: (date) 0800 Client talking on phone with loud voice. Stated “How could you spend the mortgage money on a car?” Client stated that she was talking to her husband.—-S. Smith, LPN.

Rationale 4: This entry is not appropriate, as it is five hours after the medication was refused, and does not include “late entry.”

Rationale 5: This entry describes what the nurse observed.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 19

Type: MCSA

When accessing a client’s record, the nursing student is careful to:

  1. Use the instructor’s password.
  2. Turn the monitor around when walking away from the computer.
  3. Leave notes and information in the facility’s receptacle for papers containing PHI when finished for the day.
  4. Allow only the client’s family to see the notes.

Correct Answer: 3

Rationale 1: Passwords for electronic medical records should not be shared.

Rationale 2: The student should sign out of the computer when leaving the terminal.

Rationale 3: All material with PHI (protected health information) should be left at the facility, and care plans should only include initials, to protect client confidentiality.

Rationale 4: The nurse should not allow access to a client’s record by significant others or any person other than the healthcare providers who are directly involved in the care of the client.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 20

Type: MCMA

When correcting an incorrect entry, or posting a late entry in an electronic medical record, the nurse:

Standard Text: Select all that apply.

  1. Indicates the reason for the correction.
  2. Identifies the entry as a late entry.
  3. Enters the date the entry should have been made.
  4. Signs the entry.
  5. Documents the late entries as soon as possible.

Correct Answer: 1,2,5

Rationale 1: The corrected entry should be labeled “wrong patient,” or other appropriate terminology.

Rationale 2: Late entries need to be labeled as such.

Rationale 3: Late entries need to be dated with the date the entry is being made.

Rationale 4: The entry needs to be signed per agency protocol.

Rationale 5: Late entries need to be entered as soon as possible; the longer the time lapse, the less reliable the entry becomes.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 21

Type: MCMA

Understanding the nursing process is essential to which of the following types of documentation methods?

Standard Text: Select all that apply.

  1. PIE charting
  2. APIE charting
  3. CORE DAE documentation system
  4. SOAP charting
  5. CBE

Correct Answer: 1,2,3

Rationale 1: PIE charting (problem, intervention, evaluation) is based on the nursing process.

Rationale 2: APIE charting (assessment, problem, intervention, evaluation) is based on the nursing process.

Rationale 3: CORE DAE documentation system focuses on the nursing process; it consists of a database, plans of care, flow sheets, progress notes, and discharge summary. DAE stands for data, action, evaluation.

Rationale 4: SOAP charting (subjective data, objective data, assessment, planning) is often oriented around a problem list.

Rationale 5: CBE (charting by exception) is a documentation system in which only significant findings or exceptions to norms are recorded; CBE includes unique flow sheets, documenting by reference to an agency’s printed standards of nursing practice, and documentation forms at the bedside for immediate recording.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 22

Type: MCSA

The nurse who works in a facility that is changing from a source-oriented system of documentation to the FACT system of documentation will discover that the main difference between the two is:

  1. The FACT system duplicates information.
  2. The source-oriented system duplicates information.
  3. The FACT system documents progress in DAE format.
  4. The FACT system is similar to CBE, and is designed to eliminate redundant and irrelevant data.

Correct Answer: 4

Rationale 1: The FACT system consists of flow sheets that are individualized, an assessment sheet that is standardized, concise integrated progress notes and flow sheets, and timely entries, and is computer-ready. It is efficient and time-saving.

Rationale 2: The source-oriented system tends to have duplication of information, as every caregiver makes entries in different parts of the record.

Rationale 3: The FACT system does not use the data, action, evaluation format of progress notes.

Rationale 4: The FACT system is named for its elements, and is designed to eliminate redundant and irrelevant data and inconsistencies in recording.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 23

Type: MCMA

The LPN/LVN is giving change-of-shift report to the oncoming nurse. Report on the client who has just been admitted from the Emergency Department for an asthma attack should include:

Standard Text: Select all that apply.

  1. Name, age, and room number.
  2. A list of the client’s problems.
  3. Visitors who have seen the client, including clergy.
  4. Head-to-toe review
  5. A medication list.

Correct Answer: 1,2,4

Rationale 1: Report on newly admitted clients should include diagnosis, age, general condition, plan of therapy, and information about the client’s support people.

Rationale 2: A current problem list, including priorities and changes in condition during the shift, should be included.

Rationale 3: Comings and goings of visitors is not included unless there is a problem or concern.

Rationale 4: Report on newly admitted clients should include diagnosis, age, general condition, plan of therapy, and information about the client’s support people.

Rationale 5: A current medication list for a new admission will be of interest to make sure continuity is maintained.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 24

Type: MCSA

When explaining the purpose and characteristics of reporting to the new graduate, the nurse summarizes the common features as:

  1. Individualized.
  2. Concise.
  3. Written.
  4. SBAR format.

Correct Answer: 2

Rationale 1: Reporting may be given to a group of nurses or to the nurse taking over the nurse’s assigned clients.

Rationale 2: A report should be concise, including pertinent information, but should not include any extraneous detail.

Rationale 3: Reporting may be written or oral.

Rationale 4: SBAR format (situation, background, assessment, recommendation) is a format that is useful in many reporting situations, but is not common to all reporting formats.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 25

Type: MCSA

When confirming telephone orders or other communication, the LPN/LVN documents:

  1. By whom the telephone order was received.
  2. By whom the verbal order was received.
  3. Agency protocol.
  4. 100% read back.

Correct Answer: 4

Rationale 1: Not all telephone communication involves orders; it can involve laboratory information.

Rationale 2: Not all telephone communication involves orders; it can involve laboratory information.

Rationale 3: Agency protocol should concur with regulatory agency policy.

Rationale 4: The Joint Commission requires that any information given over the phone be repeated to the caller and documented as “100% read back.”

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 26

Type: MCMA

The student nurse is attending a nursing care conference. Characteristics of the nursing care conference include:

Standard Text: Select all that apply.

  1. Discussing possible solutions to a client problem.
  2. Working together as a group to create a plan of care.
  3. A climate of respect.
  4. Discussion of nursing unit issues.
  5. Listening to others’ idea.

Correct Answer: 1,2,3

Rationale 1: The goal of the nursing care conference is to discuss possible solutions to certain client problems.

Rationale 2: Nurses work together as a group to create a plan of care that is consistent.

Rationale 3: Nurses work and communicate with a climate of respect.

Rationale 4: Discussion of other issues on the nursing unit is not appropriate at this time.

Rationale 5: The nurses at a care conference listen to each other’s ideas with an open mind to find a solution for the client problem.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 27

Type: MCMA

The LPN/LVN will often be responsible for completing the discharge note or referral summary. The information to be documented includes:

Standard Text: Select all that apply.

  1. Resolved health problems.
  2. Continuing health problems.
  3. Treatments that have been completed.
  4. Self-care abilities.
  5. Current medications.

Correct Answer: 1,2,4,5

Rationale 1: Resolved health problems need to be included as part of the database.

Rationale 2: Continuing health problems and care needs must be included for appropriate follow-up care.

Rationale 3: Treatments that are not to be continued are unnecessary to report.

Rationale 4: Self-care and functional abilities including vision and hearing should be reported to the receiving care facility.

Rationale 5: Current medications need to be included in the report so that important therapies are not interrupted.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 28

Type: MCSA

The nurse maintains accurate documentation in order to support which of the following purposes of client records?

  1. A written or computer-based communication to others
  2. A formal, legal document that provides evidence of client care
  3. An informal collection of information for others to share
  4. A formal, computer-based record of the client

Correct Answer: 2

Rationale 1: The client record is a formal, legal document of client care. A written or computer-based communication to others is a form of report. The client’s legal chart is not informal and is not always computer-based. Many agencies still rely on the written chart.

Rationale 2: The client record is a formal, legal document of client care. A written or computer-based communication to others is a form of report. The client’s legal chart is not informal and is not always computer-based. Many agencies still rely on the written chart.

Rationale 3: The client record is a formal, legal document of client care. A written or computer-based communication to others is a form of report. The client’s legal chart is not informal and is not always computer-based. Many agencies still rely on the written chart.

Rationale 4: The client record is a formal, legal document of client care. A written or computer-based communication to others is a form of report. The client’s legal chart is not informal and is not always computer-based. Many agencies still rely on the written chart.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 29

Type: MCMA

The nurse recognizes that which of the following is accurate regarding the client’s medical record? Select all that apply.

Standard Text: Select all that apply.

  1. The insurance agencies have a legal right to review the client’s chart.
  2. A client involved in a lawsuit may request that the chart be released to use as evidence.
  3. Students may not use the charts for research or educational purposes.
  4. The client must sign an authorization before the chart can be released to another professional.
  5. Written report sheets between shifts are not considered confidential.

Correct Answer: 2,4

Rationale 1: The client may request that the chart be used as evidence during a lawsuit, and must sign authorization for any information that is released from the chart. Insurance companies do not have a right to review charts unless the client provides authorization for them to see the information contained within it. Of course, failure to provide authorization releases the insurance company from obligation to reimburse for the client’s medical treatment. Students may use client charts for research and educational purposes. Any forms that contain the client’s name and information are considered confidential material.

Rationale 2: The client may request that the chart be used as evidence during a lawsuit, and must sign authorization for any information that is released from the chart. Insurance companies do not have a right to review charts unless the client provides authorization for them to see the information contained within it. Of course, failure to provide authorization releases the insurance company from obligation to reimburse for the client’s medical treatment. Students may use client charts for research and educational purposes. Any forms that contain the client’s name and information are considered confidential material.

Rationale 3: The client may request that the chart be used as evidence during a lawsuit, and must sign authorization for any information that is released from the chart. Insurance companies do not have a right to review charts unless the client provides authorization for them to see the information contained within it. Of course, failure to provide authorization releases the insurance company from obligation to reimburse for the client’s medical treatment. Students may use client charts for research and educational purposes. Any forms that contain the client’s name and information are considered confidential material.

Rationale 4: The client may request that the chart be used as evidence during a lawsuit, and must sign authorization for any information that is released from the chart. Insurance companies do not have a right to review charts unless the client provides authorization for them to see the information contained within it. Of course, failure to provide authorization releases the insurance company from obligation to reimburse for the client’s medical treatment. Students may use client charts for research and educational purposes. Any forms that contain the client’s name and information are considered confidential material.

Rationale 5: The client may request that the chart be used as evidence during a lawsuit, and must sign authorization for any information that is released from the chart. Insurance companies do not have a right to review charts unless the client provides authorization for them to see the information contained within it. Of course, failure to provide authorization releases the insurance company from obligation to reimburse for the client’s medical treatment. Students may use client charts for research and educational purposes. Any forms that contain the client’s name and information are considered confidential material.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 30

Type: MCSA

The nurse is caring for a client whose indwelling catheter was removed early this morning. Which of the following is correct documentation of urinary output for this client?

  1. The client voided a large amount of urine.
  2. The client states he voided normal amounts of urine.
  3. Voids in urinal, quantity sufficient.
  4. Voided 450 mL clear yellow urine.

Correct Answer: 4

Rationale 1: Documentation should be precise enough for others to read the information and understand exactly what is written. Words like large or sufficient are not specific, and can mean different things to different people. If the nurse documents 450 mL of urine, it is specific, and means the same thing to all who read it.

Rationale 2: Documentation should be precise enough for others to read the information and understand exactly what is written. Words like large or sufficient are not specific, and can mean different things to different people. If the nurse documents 450 mL of urine, it is specific, and means the same thing to all who read it.

Rationale 3: Documentation should be precise enough for others to read the information and understand exactly what is written. Words like large or sufficient are not specific, and can mean different things to different people. If the nurse documents 450 mL of urine, it is specific, and means the same thing to all who read it.

Rationale 4: Documentation should be precise enough for others to read the information and understand exactly what is written. Words like large or sufficient are not specific, and can mean different things to different people. If the nurse documents 450 mL of urine, it is specific, and means the same thing to all who read it.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 31

Type: MCSA

The nurse converts 3:17 p.m. to what time using military time?

  1. 1317
  2. 0317
  3. 1517
  4. 2017

Correct Answer: 3

Rationale 1: Military time is often used to prevent errors in time interpretation. 3:17 p.m. is 1517 in military time.

Rationale 2: Military time is often used to prevent errors in time interpretation. 3:17 p.m. is 1517 in military time.

Rationale 3: Military time is often used to prevent errors in time interpretation. 3:17 p.m. is 1517 in military time.

Rationale 4: Military time is often used to prevent errors in time interpretation. 3:17 p.m. is 1517 in military time.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 32

Type: MCSA

The nurse accepts which of the following as proper legal documentation of complete bedrest for three days?

  1. CBR for three days
  2. CBR X3d
  3. BR for three days
  4. CBR for 3d

Correct Answer: 1

Rationale 1: CBR is complete bedrest, and is an acceptable abbreviation. Three days should be written out because X3d could be misinterpreted.

Rationale 2: CBR is complete bedrest, and is an acceptable abbreviation. Three days should be written out because X3d could be misinterpreted.

Rationale 3: CBR is complete bedrest, and is an acceptable abbreviation. Three days should be written out because X3d could be misinterpreted.

Rationale 4: CBR is complete bedrest, and is an acceptable abbreviation. Three days should be written out because X3d could be misinterpreted.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 33

Type: MCMA

Which of the following does the nurse use as a legally acceptable abbreviation? Select all that apply.

Standard Text: Select all that apply.

  1. q.d.
  2. MS
  3. BM
  4. TPR
  5. Lab.

Correct Answer: 3,4,5

Rationale 1: BM (bowel movement), TPR (vital signs), and lab. (laboratory) are all acceptable abbreviations that may be used in a medical facility. The Joint Commission has identified q.d. (every day) and MS (could be interpreted as morphine sulfate, magnesium sulfate, or multiple sclerosis) as unacceptable abbreviations.

Rationale 2: BM (bowel movement), TPR (vital signs), and lab. (laboratory) are all acceptable abbreviations that may be used in a medical facility. The Joint Commission has identified q.d. (every day) and MS (could be interpreted as morphine sulfate, magnesium sulfate, or multiple sclerosis) as unacceptable abbreviations.

Rationale 3: BM (bowel movement), TPR (vital signs), and lab. (laboratory) are all acceptable abbreviations that may be used in a medical facility. The Joint Commission has identified q.d. (every day) and MS (could be interpreted as morphine sulfate, magnesium sulfate, or multiple sclerosis) as unacceptable abbreviations.

Rationale 4: BM (bowel movement), TPR (vital signs), and lab. (laboratory) are all acceptable abbreviations that may be used in a medical facility. The Joint Commission has identified q.d. (every day) and MS (could be interpreted as morphine sulfate, magnesium sulfate, or multiple sclerosis) as unacceptable abbreviations.

Rationale 5: BM (bowel movement), TPR (vital signs), and lab. (laboratory) are all acceptable abbreviations that may be used in a medical facility. The Joint Commission has identified q.d. (every day) and MS (could be interpreted as morphine sulfate, magnesium sulfate, or multiple sclerosis) as unacceptable abbreviations.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 34

Type: MCSA

The nurse offers to bathe the client, and the client declines. What is the best way for the nurse to document this situation?

  1. The client is refusing all care today.
  2. The client is being noncompliant today.
  3. Client stated, “I do not want a bath today.”
  4. The client did not want a bath today.

Correct Answer: 3

Rationale 1: Whenever possible, it is best to record the client’s actual statement. To say that the client is refusing all care today is inaccurate, as the client only refused the bath. Writing that the client is noncompliant is a judgment. Charting that the client did not want a bath is inaccurate because perhaps the client did want a bath but didn’t want it at that time. If charting exactly what the client said, there can be no misinterpretation.

Rationale 2: Whenever possible, it is best to record the client’s actual statement. To say that the client is refusing all care today is inaccurate, as the client only refused the bath. Writing that the client is noncompliant is a judgment. Charting that the client did not want a bath is inaccurate because perhaps the client did want a bath but didn’t want it at that time. If charting exactly what the client said, there can be no misinterpretation.

Rationale 3: Whenever possible, it is best to record the client’s actual statement. To say that the client is refusing all care today is inaccurate, as the client only refused the bath. Writing that the client is noncompliant is a judgment. Charting that the client did not want a bath is inaccurate because perhaps the client did want a bath but didn’t want it at that time. If charting exactly what the client said, there can be no misinterpretation.

Rationale 4: Whenever possible, it is best to record the client’s actual statement. To say that the client is refusing all care today is inaccurate, as the client only refused the bath. Writing that the client is noncompliant is a judgment. Charting that the client did not want a bath is inaccurate because perhaps the client did want a bath but didn’t want it at that time. If charting exactly what the client said, there can be no misinterpretation.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 35

Type: MCSA

The client asks for a copy of his medical record. The best response by the nurse is which of the following?

  1. “I’m sorry, but we are not allowed to give you a copy of the chart.”
  2. “I will get that for you right away.”
  3. “I will have to get permission from the doctor.”
  4. “I will need a written request from you to send to Medical Records.”

Correct Answer: 4

Rationale 1: The client has a right to obtain a copy of the chart, but the request must be written, and there might be a charge for the copy. Telling the client that providing a copy of the chart is not allowed is not true. The student may not copy the chart for the client, it must be copied by the Medical Records department, and permission from the doctor is not required. However, it would be a courtesy to notify the doctor that the client requested a copy of the chart.

Rationale 2: The client has a right to obtain a copy of the chart, but the request must be written, and there might be a charge for the copy. Telling the client that providing a copy of the chart is not allowed is not true. The student may not copy the chart for the client, it must be copied by the Medical Records department, and permission from the doctor is not required. However, it would be a courtesy to notify the doctor that the client requested a copy of the chart.

Rationale 3: The client has a right to obtain a copy of the chart, but the request must be written, and there might be a charge for the copy. Telling the client that providing a copy of the chart is not allowed is not true. The student may not copy the chart for the client, it must be copied by the Medical Records department, and permission from the doctor is not required. However, it would be a courtesy to notify the doctor that the client requested a copy of the chart.

Rationale 4: The client has a right to obtain a copy of the chart, but the request must be written, and there might be a charge for the copy. Telling the client that providing a copy of the chart is not allowed is not true. The student may not copy the chart for the client, it must be copied by the Medical Records department, and permission from the doctor is not required. However, it would be a courtesy to notify the doctor that the client requested a copy of the chart.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 36

Type: MCSA

After documenting in the client’s medical record, the nurse realizes it was the wrong medical record, and the charting was for another client. The nurse’s priority action is to do which of the following?

  1. Use a permanent marker to black out the entry so that it cannot be read.
  2. Pull out the page and discard it, and reenter the information in the other client’s record.
  3. Draw an X through the entry and write “error, wrong chart,” and sign and date.
  4. Cover the entry with brush-on correction fluid.

Correct Answer: 3

Rationale 1: Draw an X through the entry and write “error, wrong chart,” and sign and date. Pulling out the page would also delete other entries that are legal parts of the record. Using white-out or a marker is not acceptable because it obliterates the information.

Rationale 2: Draw an X through the entry and write “error, wrong chart,” and sign and date. Pulling out the page would also delete other entries that are legal parts of the record. Using white-out or a marker is not acceptable because it obliterates the information.

Rationale 3: Draw an X through the entry and write “error, wrong chart,” and sign and date. Pulling out the page would also delete other entries that are legal parts of the record. Using white-out or a marker is not acceptable because it obliterates the information.

Rationale 4: Draw an X through the entry and write “error, wrong chart,” and sign and date. Pulling out the page would also delete other entries that are legal parts of the record. Using white-out or a marker is not acceptable because it obliterates the information.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 37

Type: MCSA

When documenting in the client’s computerized medical record, which of the following actions by the nurse might result in a breach of client confidentiality?

  1. The nurse uses a password to access the client’s record.
  2. The nurse is chatting with a co-worker while the medication record is on the screen.
  3. The nurse turns the monitor so that it is not visible from the hallway.
  4. The nurse closes the client’s record and signs off the computer when done.

Correct Answer: 2

Rationale 1: The co-worker is not caring for the client, and should not be viewing anything about the client. All other actions by the nurse are appropriate.

Rationale 2: The co-worker is not caring for the client, and should not be viewing anything about the client. All other actions by the nurse are appropriate.

Rationale 3: The co-worker is not caring for the client, and should not be viewing anything about the client. All other actions by the nurse are appropriate.

Rationale 4: The co-worker is not caring for the client, and should not be viewing anything about the client. All other actions by the nurse are appropriate.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 38

Type: MCSA

While reviewing a client’s lab results, the nurse also checks the results of a throat culture performed yesterday on the client’s son. Which of the following is an accurate statement regarding this action?

  1. The nurse breached confidentiality.
  2. The nurse can legally check this information if the child is under age 18.
  3. The nurse should ask Medical Records for the son’s results.
  4. The nurse should ask another nurse to look up the information.

Correct Answer: 1

Rationale 1: The nurse breached confidentiality, as she was not caring for the son, and had no right to access that record, even if the child is under 18. The doctor’s nurse and the nurse caring for the son cannot give the information to the nurse. Medical Records cannot give the information to the nurse.

Rationale 2: The nurse breached confidentiality, as she was not caring for the son, and had no right to access that record, even if the child is under 18. The doctor’s nurse and the nurse caring for the son cannot give the information to the nurse. Medical Records cannot give the information to the nurse.

Rationale 3: The nurse breached confidentiality, as she was not caring for the son, and had no right to access that record, even if the child is under 18. The doctor’s nurse and the nurse caring for the son cannot give the information to the nurse. Medical Records cannot give the information to the nurse.

Rationale 4: The nurse breached confidentiality, as she was not caring for the son, and had no right to access that record, even if the child is under 18. The doctor’s nurse and the nurse caring for the son cannot give the information to the nurse. Medical Records cannot give the information to the nurse.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 39

Type: MCSA

The newly hired nurse is being oriented to the charting system used at the employing facility. The preceptor tells the nurse to find the nursing section of the client’s record and document vital signs and AM care. The nurse recognizes the form of documentation used at this facility is which of the following?

  1. Problem-oriented charting
  2. SOAP charting
  3. Source-oriented charting
  4. Fact-oriented charting

Correct Answer: 3

Rationale 1: In source charting, each discipline has its own area in the client record for charting. SOAP is a method of charting narrative interventions. Problem-oriented records are charted by each discipline according to the client problems. FACT charting uses a system of flow sheets that are individualized for the client.

Rationale 2: In source charting, each discipline has its own area in the client record for charting. SOAP is a method of charting narrative interventions. Problem-oriented records are charted by each discipline according to the client problems. FACT charting uses a system of flow sheets that are individualized for the client.

Rationale 3: In source charting, each discipline has its own area in the client record for charting. SOAP is a method of charting narrative interventions. Problem-oriented records are charted by each discipline according to the client problems. FACT charting uses a system of flow sheets that are individualized for the client.

Rationale 4: In source charting, each discipline has its own area in the client record for charting. SOAP is a method of charting narrative interventions. Problem-oriented records are charted by each discipline according to the client problems. FACT charting uses a system of flow sheets that are individualized for the client.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 40

Type: MCSA

The nurse is documenting with a system that requires an action and a response category. What type of charting system is the nurse using?

  1. CBE
  2. FOCUS
  3. SOAP
  4. CORE

Correct Answer: 2

Rationale 1: The FOCUS method requires action and responses. CBE is charting by exception. SOAP is a method of recording data using subjective, objective, assessment, and planning data, while CORE is charting focusing on the nursing process.

Rationale 2: The FOCUS method requires action and responses. CBE is charting by exception. SOAP is a method of recording data using subjective, objective, assessment, and planning data, while CORE is charting focusing on the nursing process.

Rationale 3: The FOCUS method requires action and responses. CBE is charting by exception.SOAP is a method of recording data using subjective, objective, assessment, and planning data, while CORE is charting focusing on the nursing process.

Rationale 4: The FOCUS method requires action and responses. CBE is charting by exception. SOAP is a method of recording data using subjective, objective, assessment, and planning data, while CORE is charting focusing on the nursing process.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 41

Type: MCSA

The nurse receives a telephone order from the provider. Which of the following actions by the nurse is appropriate?

  1. Write the main points of the order on a piece of paper to be transcribed later.
  2. Consult with another nurse before documenting if the order is confusing.
  3. Write the medication order as 25.0 milligrams on the physician’s order sheet.
  4. Have the chart available in case the physician has questions.

Correct Answer: 4

Rationale 1: When taking a verbal order, the nurse write the order as the physician gives it to her on the chart, and then repeats the order back to the physician for verification. The nurse should have the chart available to answer the physician’s questions as well. When writing medication orders, a whole number is never followed by a decimal point and zero, because the decimal point could be missed, and the client would receive 10 times the ordered dosage. If the order is confusing, the nurse should clarify the order before hanging up with the provider. Writing the order on a piece of paper, instead of directly into the medical record, risks losing the paper or improperly transcribing the order.

Rationale 2: When taking a verbal order, the nurse write the order as the physician gives it to her on the chart, and then repeats the order back to the physician for verification. The nurse should have the chart available to answer the physician’s questions as well. When writing medication orders, a whole number is never followed by a decimal point and zero, because the decimal point could be missed, and the client would receive 10 times the ordered dosage. If the order is confusing, the nurse should clarify the order before hanging up with the provider. Writing the order on a piece of paper, instead of directly into the medical record, risks losing the paper or improperly transcribing the order.

Rationale 3: When taking a verbal order, the nurse write the order as the physician gives it to her on the chart, and then repeats the order back to the physician for verification. The nurse should have the chart available to answer the physician’s questions as well. When writing medication orders, a whole number is never followed by a decimal point and zero, because the decimal point could be missed, and the client would receive 10 times the ordered dosage. If the order is confusing, the nurse should clarify the order before hanging up with the provider. Writing the order on a piece of paper, instead of directly into the medical record, risks losing the paper or improperly transcribing the order.

Rationale 4: When taking a verbal order, the nurse write the order as the physician gives it to her on the chart, and then repeats the order back to the physician for verification. The nurse should have the chart available to answer the physician’s questions as well. When writing medication orders, a whole number is never followed by a decimal point and zero, because the decimal point could be missed, and the client would receive 10 times the ordered dosage. If the order is confusing, the nurse should clarify the order before hanging up with the provider. Writing the order on a piece of paper, instead of directly into the medical record, risks losing the paper or improperly transcribing the order.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 42

Type: MCSA

When providing report to the oncoming shift, which of the following data would the nurse exclude from the change of shift report?

  1. Mr. Timby received 50 mg of Demerol IM at 0430.
  2. Mrs. Buxtom’s vital signs were stable throughout the night.
  3. Mr. Lynn and Mr. Jones were discharged tonight.
  4. Mr. Shelby’s wife assists in giving care to her husband.

Correct Answer: 3

Rationale 1: Since the clients are no longer in the facility, the next shift does not need to know that Mr. Lynn and Mr. Jones were discharged. The oncoming nurse needs to know about medications, vital signs, and concerns expressed by the family of the client they’ll be caring for throughout the shift.

Rationale 2: Since the clients are no longer in the facility, the next shift does not need to know that Mr. Lynn and Mr. Jones were discharged. The oncoming nurse needs to know about medications, vital signs, and concerns expressed by the family of the client they’ll be caring for throughout the shift.

Rationale 3: Since the clients are no longer in the facility, the next shift does not need to know that Mr. Lynn and Mr. Jones were discharged. The oncoming nurse needs to know about medications, vital signs, and concerns expressed by the family of the client they’ll be caring for throughout the shift.

Rationale 4: Since the clients are no longer in the facility, the next shift does not need to know that Mr. Lynn and Mr. Jones were discharged. The oncoming nurse needs to know about medications, vital signs, and concerns expressed by the family of the client they’ll be caring for throughout the shift.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 43

Type: MCSA

The nurse is visiting the client in the home to complete dressing changes and administer antibiotics. The nurse finishes care, and is preparing to document findings and care given. Which of the following is accurate regarding the charting for the home health nurse?

  1. The nurse retrieves the chart from the physician’s office before the visit.
  2. The primary nurse keeps the chart at all times.
  3. The chart is kept with the client so that the family can chart events.
  4. The nurse obtains the cart from the agency before the visit.

Correct Answer: 3

Rationale 1: In home health care, many different disciplines might be delivering care, including the family. The chart is kept at the client’s bedside in the home so that it is available to all caregivers providing care, including the family.

Rationale 2: In home health care, many different disciplines might be delivering care, including the family. The chart is kept at the client’s bedside in the home so that it is available to all caregivers providing care, including the family.

Rationale 3: In home health care, many different disciplines might be delivering care, including the family. The chart is kept at the client’s bedside in the home so that it is available to all caregivers providing care, including the family.

Rationale 4: In home health care, many different disciplines might be delivering care, including the family. The chart is kept at the client’s bedside in the home so that it is available to all caregivers providing care, including the family.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

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