Exam Review

Which is the first action of the nurse when starting care for the patient at the beginning of the shift?
A)
Perform a focused patient assessment.
B)
Administer prescribed medication.
C)
Create the nursing plan of care for the patient.
D)
Determine the patient's family history.
Which patient's needs must be addressed first by the nurse?
A)
The patient who is nauseated and vomiting after receiving narcotic pain medication.
B)
The constipated patient who needs to use the toilet after receiving a laxative.
C)
The patient who is waiting for discharge teaching in order to go home.
D)
The patient with chest pain and shortness of breath after two doses of sublingual nitroglycerin.
Which chart entry represents appropriate documentation about the patient's pain assessment?
A)
The patient is sleeping comfortably.
B)
The patient rated the pain at 2 on a 0-to-10 scale.
C)
The patient appears not to be in any pain.
D)
The patient always complains about being in pain.
Which of the following statements are true regarding hand-off reports? Select the 3 correct answers.
(SATA)
A)
Must be given face to face between the nurses.
B)
Provides for the continuity and individualized care of the patient.
C)
Must include an opportunity for the receiver to ask querry of the person giving the report.
D)
Includes up-to-date and recent changes about the patient.
E)
Takes the place of documentation.

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Exam Review

The person responsible for analyzing and interpreting data to arrive at a nursing diagnosis is the:
A)
Physician.
B)
Patient.
C)
Nurse.
D)
Therapist.
The physician orders 350,000 units of Penicillin G IM now for a patient with a positive strep infection. What is the most appropriate diluent amount for this patient? See LABEL #1 (Penicillin G)
Correct Answer:9.6 mL of sterile water
The major difference between the nursing diagnoses "inadequate nutritional intake related to vomiting as manifested by 3-pound weight loss" and "risk for impaired skin integrity related to inadequate nutrition" is that the second diagnosis:
A)
Reflects a problem that does not yet exist.
B)
Needs no defined nursing interventions.
C)
Will not need to be evaluated.
D)
Needs medical intervention.
Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system?
A)
"I won't have to worry about reading the doctor's messy handwriting anymore.”.
B)
"It will likely reduce the time spent on manual documentation.”.
C)
"I am thankful that I won't have to keep changing my passwords all the time.”.
D)
"I'll be able to see my son's medical record using my password and user ID.”.

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Exam Review

A nurse is reviewing new orders for an ambulate patient four times a day.
A)
AC & HS.
B)
NG.
C)
DNR.
D)
STAT.
The nurse becomes frustrated when a patient insists on taking herbal remedies rather than prescribed medications and spends certain hours of each day in prayer.The patient also prefers the care of the spiritual healer over the attending physician.Which factor may be responsible for the nurse's frustration?
A)
Incorrect organization of health assessment findings.
B)
Impaired ability of the patient to cope with acute illness.
C)
Cultural differences in health-related practices.
D)
Delay in the patient's psychosocial development.
A nurse is preparing to document a client's information in the electronic medical record.Which of the following nursing statements identifies the purpose of documentation?
A)
"Documentation enables providers to monitor the nurse.”.
B)
"Documentation provides a communication tool for the health care team.”.
C)
"Documentation provides information for a client audit.”.
D)
"Documentation facilitates reimbursement from the local government.”.
When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:
A)
SBAR.
B)
Focused charting.
C)
Charting by exception.
D)
SOAP.

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Exam Review

Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:
A)
Share information only with the family.
B)
Have a clinical reason for reading the record.
C)
Provide information only to another nurse.
D)
Provide information only to an attorney.
The nurse is caring for an unconscious patient.The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.What is the rationale for these actions?
A)
Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel.
B)
The nurse identifies the patient care areas in which additional assistance is required.
C)
The nurse realizes the potential for pressure injuries and acts to prevent their development.
D)
The nurse is following the standing orders listed in the patient's medical record.
Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system?
A)
"I won't have to worry about reading the doctor's messy handwriting anymore.”.
B)
"It will likely reduce the time spent on manual documentation.”.
C)
"I am thankful that I won't have to keep changing my passwords all the time.”.
D)
"I'll be able to see my son's medical record using my password and user ID.”.
A nurse is discussing informatics with a newly licensed nurse.The nurse identifies that informatics is defined as the use of information and technology for which of the following?
A)
Producing clinical pathways.
B)
Managing knowledge.
C)
Preventing burnout.
D)
Providing a safe place to administer care.

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Exam Review

An example of an appropriate nursing diagnosis is:
A)
Patient will report increased activity tolerance within 4 days.
B)
Patient will have improved nutritional intake in 3 days, as evidenced by eating 75% of a protein-rich meal and a 1-1.5 lb weight gain.
C)
Impaired physical mobility related to extreme weakness as evidenced by the inability to perform active ROM exercises, inability to transfer from bed to chair, and use of a walker when ambulating.
D)
Impaired skin integrity due to the patient being lazy as evidenced by a 5cm x 2cm x 1/2 cm stage III ulcer noted on the coccyx, an unstageable wound on the left heel, and a reddened area on the right elbow.
A charge nurse is reinforcing teaching with a newly licensed nurse about accessing a client's medical records.Which of the following should the nurse include?
A)
A nurse can only access the records of clients they are actively caring for.
B)
A nurse can access the records of any client in the healthcare facility, as long as the information is not shared.
C)
A nurse can only share information from the client's medical record with immediate family members.
D)
A nurse can share information about a client with clients who have a similar diagnosis.
A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the Intervention?
A)
Client had 50 ml of emesis in the last hour.
B)
Client reports nausea and vomiting.
C)
Ondansetron 4 mg IM bolus given for nausea and vomiting.
D)
Client is asleep and resting comfortably.
The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended query will provide the nurse with helpful information about the patient's health status?
A)
Are you having any difficulty breathing right now?
B)
How long have you been experiencing chest pain?
C)
What does your chest pain feel like?
D)
Do you have a family history of heart disease?. . .

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Exam Review

A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse.Which of the following should the charge nurse include in the teaching? (Select 3 options)
A)
Data contained in a client's medical record can be shared with all employees within a health care facility.
B)
Documentation should include the nurse's interpretation of the client situation.
C)
A medical record can be used as evidence in a court of law.
D)
A nurse should ensure the documentation is organized and completed in a timely fashion.
E)
Information recorded in the client's medical record must be accurate.
The client in room 108 has been prescribed new pain medication.A nurse is providing change-of-shift report to the oncoming nurse.Which of the following information should the nurse include in the report?
A)
The family of the client in room 107.
B)
The client in room 105 had a bath.
C)
The client in room 108 received a new pain medication.
D)
The dietary preferences of the client in room 109.
The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient’s chart demonstrates that the teaching was successful?
A)
Additional written instructions about how to perform the injection was provided.
B)
The patient denied having any asks or concerns about the procedure.
C)
The patient correctly self-administered his next scheduled dose of insulin.
D)
The patient identified the steps and equipment used.
The nurse is caring for a nonverbal client who is moaning with position changes, the hands and teeth are clenched, and the skin is very diaphoretic.The nurse interprets this as the client is experiencing pain and decides to administer an analgesic.What is the correct term for this nursing action?
A)
Setting priorities.
B)
Recognizing inconsistencies.
C)
Making inferences.
D)
Using empathy.

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