Module 2

While gathering data, the nurse discovers that the patient is suffering from a life threatening disorder. Of the care priorities below, which category is this patient's care?
Low-priority
High-priority
Ultimate-priority
Medium-priority

High-priority

What does the nurse use as a basis for documentation in focus charting?
Problem list
Nursing orders
Patient problems
Evaluation

Patient problems

Which document should the nurse manager check to verify a patient's progress?
O Consultation sheet
O Admission form
O Flow sheet
O Ancillary staff sheet

Flow sheet
Rationale: The flow sheet tracks routine assessments, treatments, and frequently given care; hence, the nurse manager has to check the flow sheet to understand the patient's progress. The consultation sheet is a record of an
additional primary

How can the nurse make nurses' notes brief? Select all that apply
Use abbreviations
Replace words with their synonyms
Cut down on the amount of information
use symbols and acronyms
Replace detailed sentences with matter of fact statements
Remove all the m

Use abbreviations
Replace words with their synonyms
use symbols and acronyms
Replace detailed sentences with matter of fact statements

A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurse's focus?
Planning
Assessment
Implementation
Patient teaching

Assessment
Rational: DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and

The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem that may increase because of the use of SRDs? (Select all that apply.)
Immobility
Lethargy
Risk for impaired circulation
Risk for skin impairment
Incontinence

Immobility
Risk for impaired circulation
Risk for skin impairment
Incontinence

What are the three buffer systems of the body? (Select all that apply.)
Bicarbonate/carbonic acid system
Respiratory system
Renal system
GI system
Integumentary system

Bicarbonate/carbonic acid system
Respiratory system
Renal system
Rational: The bicarbonate/carbonic acid system, the respiratory system, and the renal system are the buffer systems of the body.

The opposite term for posterior in humans is
superior.
anterior.
ventral.
both B and C.

Both B and C

complex nursing situation

Patient's clinical condition is not predictable. Medical and nursing orders are likely to involve continuous changes or complex modifications.

activities of daily living (ADLs)

basic self-care tasks such as eating, bathing, toileting, walking, and dressing

Which describes the anatomical relationship of the wrist to the elbow?
The elbow is proximal to the wrist.
The elbow is distal to the wrist.
The elbow is superficial to the wrist.
The elbow is lateral to the wrist.

The elbow is proximal to the wrist.

Which of these organs is an accessory organ of the digestive system?
Stomach
Liver
Esophagus
Small intestine

Liver

Eight categories of disciplinary actions taken against nurses

1. Fraud and deceit
2. Criminal Activity
3. Negligence
4. Violation of NPA
5. Discipline by another jurisdiction
6. Incompetence
7. Unethical conduct
8. Alcohol and/or other drug abuse

Which format of documentation involves the health care team using the same progress
notes, flow sheets, and narrative notes?
O Charting by exception (CBE)
O Problem-oriented medical record (POMR)
OProblem Intervention Evaluation
O(PIE) charting
O subjecti

Problem-oriented medical record (POMR)
Rationale: The POMR is organized according to the scientific problem-solving method. The problem list serves as the Index A team of primary health care provider, nurses, and therapists develop a care plan. All are re

interstate endorsement

Agreement among states that licensed nurses do not have to repeat NCLEX-PN exam if they meet criteria for working in the state.

multi-state licensure

agreement with another state that says if you're licensed in one state your licensed in another

clinical pathways

standardized multidisciplinary plans for a specific diagnosis or procedure that identify specific aspects of care to be performed during a designated length of stay

criminal action

deals with disputes between an individual and the society as a whole

Malpractice

Failure by a health professional to meet accepted standards

The nurse is teaching nursing students about the activities involved in determining a patient problem. Which action by the nursing student indicates the need for additional teaching?
Checking the patient for activity intolerance and functional ability
Ask

Informing the patient that he or she has diabetes mellitus as indicated by elevated glucose levels

During which phase of the nursing process would the nurse anticipate possibly making modifications to the nursing care plan?
Planning
Evaluation
Assessment
Goal Identification
.

Evaluation
Rational: Changes are often made in the evaluation phase if the identified goals were not met. The nurse generally does not anticipate making changes during the planning, assessment, or goal identification phases.

Which function does the patient goal statement serve on a patient's care plan? Select all
that apply.
Establishes priorities for nursing care
Guides selection of nursing interventions
Identifies the patient's response to a health problem
Reduces or elimin

Guides selection of nursing interventions
Establishes measuring standards to evaluate nursing intervention effectiveness

While orienting to a new facility, which statement by the nurse to the nurse preceptor indicates accurate understanding of a clinical pathway?
O "It refers to a system of care where patient care is coordinated by one nurse or person."
O This process refer

it is a multidisciplinary plan of care that incorporates evidence-based practice to provide optimal patient outcomes.

Which source of data is included in resources the nurse may use as secondary sources of
data? Select all that apply
Patient
Dietitians
Medical records
Previous nursing progress notes
Physical therapists
Diagnostic procedures

Dietitians
Medical records
Previous nursing progress notes
Physical therapists
Diagnostic procedures

Which interventions can a nurse prescribe or initiate legally? Select all that apply.
Codeine
Wound care
Back massage
clear liquid diet
Relaxation exercises
Turning every 2 hours

Back massage
Relaxation exercises
Turning every 2 hours

A nurse has completed the initial data collection from a patient with a chronic mental disorder. How does the nurse organize and cluster data?
Obtain diagnostic tests.
Perform a physical assessment.
Consider the assessment database.
Determine the desired

Consider the assessment database.

An infant is born in an unstable condition into a Roman Catholic Family. The nurse understands that the child may die without being seen by a priest. Which intervention would be included in the plan of care?
Baptism
Communion
Last rites
Prayer

Baptism

A clinical pathway is a tool for which type of health care?
Low-risk, low-volume, low-cost cases
High-risk, low-volume, low-cost cases
High-risk, high-volume, high-cost cases
High- or low-risk, high- or low-volume, high- or
low-cost cases

High-risk, high-volume, high-cost cases

The nurse collects data from a patient admitted to a long-term care facility. Which actions are important aspects of planning care for this patient? Select all that apply.
Set goals to eliminate identified problems.
Evaluate the patient's response to the

Collaborate with the patient before choosing the intervention
Set goals to eliminate identified problems.

The nurse administers pain medication to a patient who rates his postoperative pain as a 9 on a scale of 1 to 10. Which nursing intervention evaluates the effectiveness of the intervention? Select all that apply.
Document the patient's response.
Add colle

Compare pre- and post-pain assessment data.
Determine whether the expected outcome was achieved.
Determine whether the intervention was effective and take further action, if needed.

Which components are necessary for a well-written patient outcome statement or goal?
Select all that apply
Being specific to the patient
Being realistic for the patient
Including a time frame for completion
Giving indications of a worsening of the problem

Being specific to the patient
Being realistic for the patient
Including a time frame for completion

During which phase of the nursing process would the nurse anticipate possibly making
modifications to the nursing care plan?
O Planning
O Evaluation
O Assessment
O Goal Identification

O Evaluation

While the nurse is collecting data, the patient states, "I have had diarrhea for 3 days." The
nurse notes this as which type of data?
Tertiary
Primary
Secondary
Secondhand

Primary

Which components are necessary for a well-written patient outcome statement or goal? Select all that apply.
Being specific to the patient
Being realistic for the patient
Including a time frame for completion
Giving indications of a worsening of the proble

Being specific to the patient
Being realistic for the patient
Including a time frame for completion

Clinical (Critical) Pathways

- A systematic approach that provides a framework to target the coordination of medical and nursing interventions
- Allows staff from all disciplines to develop integrated care plans for a projected length of stay for a specific case type

Diagnosis-related groups

A system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount

Omnibus Budget Reconciliation Act (OBRA) 1987

Regulated standards for resident assessment, individualized care plans, and qualifications for health care providers

The Joint Commission

- The accreditation agency specifying guidelines for charting
- Documentation of client care, time it was provided &signature of the person who is documenting, provesthat the Person who signed it, did all the work noted& interventions were carried out to

DARE

Acronym used for the focused charting format

Problem-oriented medical record (POMR)

Method of recording data about the health status of a patient in a problem-solving system. Parts included are the database, problem list, initial plan, and progress notes

SBAR

A method of communication among health care workers and a part of documentation; considered a safety measure in preventing errors from poor communication during hand-off or hand-over interactions

Kardex, or Rand

A system used to consolidate patient orders and care needs in a centralized, concise way

Electronic Health Record (EHR)

An electronic patient record designed for health information exchange between facilities

Which function does the patient goal statement serve on a patient's care plan? Select all that apply.
Establishes priorities for nursing care
Guides selection of nursing interventions
Identifies the patient's response to a health problem
Reduces or elimin

Guides selection of nursing interventions
Establishes measuring standards to evaluate nursing intervention effectiveness

patient complains of breathlessness. Which nursing action is a part of the implementation phase of the nursing process?
Assess the respiratory rate.
Plan to provide oxygen therapy
Prop up the patient in Fowler's position
Assess whether the patient is feel

Prop up the patient in Fowler's position

When a nurse reflects on care that was given and determines what was effective, in addition to analyzing and adjusting given care, which process is involved?
Critical thinking
The nursing notes
The patient problem statement
The nursing care plan

Critical thinking

Which nursing action is inappropriate during the initial assessment phase?
Obtaining patient history
Referring to the assessment database
Performing the physical assessment
Gathering the results of diagnostic test

Referring to the assessment database

Which characteristic of a well-written goal statement is not met in the goal statement:
Patient will understand how to use a sliding scale to administer insulin coverage to manage blood sugar levels by discharge to home?
Uses a measurable verb
Is realisti

Uses a measurable verb

While orienting to a new facility, which statement by the nurse to the nurse preceptor indicates accurate understanding of a clinical pathway?
"It refers to a system of care where patient care is coordinated by one nurse or person.
"This process refers to

It is a multidisciplinary plan of care that incorporates evidence-based practice to provide optimal patient outcomes.

While reviewing the patient's nursing care plan to prepare for the shift, which statement would the nurse identify as a nurse-prescribed intervention?
Administer 10 units of insulin glargine each day at bedtime.
Patient correctly identified signs and symp

Educate patient about maintaining a healthy weight and regular physical activity to manage diabetes before discharge.

After 2 hours, a nurse asks a patient to rate the abdominal pain. The patient replies, "The pain is just as bad as it was before I took the medication." Which intervention would be appropriate in response to the patient's statement?
Monitor the patient fo

Reassess the source of the pain to determine why pain relief has not occurred.

For a patient being evaluated for shortness of breath, which data would the nurse consider signs or objective data?
Nurse notes breathing is very noisy.
Patient reports feeling short of breath.
Respiratory rate is 26 breaths/min.
Patient is using accessor

Nurse notes breathing is very noisy.
Respiratory rate is 26 breaths/min.
Patient is using accessory muscles to breathe.
Patient is sitting in the high-Fowler's position to help ease breathing

A nursing student is completing clinical forms. If found on the medical records, which diagnosis would the student research to prepare care for this patient?
Emphysema
Knowledge deficit
Alteration in nutrition
Ineffective airway exchange

Emphysema
Rationale: Emphysema is a medical diagnosis, which is the identification of a disease or condition based on evaluation of physical signs, symptoms, patient interview, laboratory test results, findings of diagnostic procedures, review of medical

Which phrase best describes the outcomes identification phase of the nursing
process?
Select all that apply
The information received from the patient during a physical assessment
A set of expected obligations the patient is required to meet at discharge
E

Expected outcomes for diagnoses developed by the patient and the nurse

Which action would the nurse take when documenting
O clearly indicating goal-directed nursing care
O Minimizing nursing notes to address priority nursing problems
O Providing information about adverse events that
occur throughout the day
O Documenting sub

clearly indicating goal-directed nursing care

When reviewing charting documented using the SOAPE model, which entry under the "S"
portion of the model requires correction?
O "Nurse to continue to measure wound once a week."
O "Dressing changed with sterile 4 x4 wrapped with gauze."
"Patient reports p

Patient reports pain level of 8 out of 10 during dressing changes.

When caring for a patient with pneumonia, which information would the nurse refrain from documenting in the patient's chart?
Is not listening to information
Shortness of breath on exertion
Requires a walker for ambulation
Refuses to use incentive spiromet

Is not listening to information

A nurse on the evening shift reviews a chart and finds that the patient did not receive a morning dose of insulin as prescribed. After notifying the charge nurse, which nursing action is priority?
Administer the medication and check the glucose level.
Com

Complete an incident report according to hospital policy

Which statement regarding information included in the Kardex system is true?
O It includes only personal information.
O It details only scheduled tests.
O It covers the medication list without citing details of allergies.
O It includes only surgery-relate

It covers the medication list without citing details of allergies.

What is a common injury that occurs at health care facilities?

Falls

What materials are include in each type of fire
1. Type A
2. Type B
3. Type C

1. paper, wood, cloth
2. flammable liquids, grease and anesthetics
3. Electrical

Two kinds of biological attacks

1. Overt (announced)
2. Covert (unannounced)

When should possibility of a bioterrorism-related outbreak be considered?

1. Rapidly increasing incidence of a disease is normally healthy population
2. Unusual increase in number of people seeking care (fever, respiratory, gastrointestinal)
3. Epidemic disease
4. Lower incidence of people getting sick indoors compared to outdo

The majority of falls occur during _____ either to a beside commode or to a wheelchair

transfer

Whenever using a gait belt which side of patient do you walk on

weak side

How to evaluate use of SRD

1. make sure used correctly
2. Asses body party every 30 minutes, release every 2 hours.

Define Sentinel Event

any unexpected occurrence involving death, serious physical/psychological injury or the risk.

The nurse is teaching nursing students about the activities involved in determining a patient problem. Which action by the nursing student indicates the need for additional teaching?
Checking the patient for activity intolerance and functional ability
Ask

Asking whether the patient has urinary stress, incontinence, and related signs