Nursing Informatics

What does the nurse conclude is related directly to an infant's survival in the neonatal period? 1. Gestational age and birth weight 2. Reproductive history of the mother 3. Parental health habits and social class 4. Adequacy of the mother's prenatal care

1. Gestational age and birth weight RATIONALE: Adaptation to the extrauterine environment is largely dependent on the functional capacity of vital organ systems, which is established during intrauterine development; this is measurable in terms of gestational age and weight. Although the reproductive history of the mother, parental health habits, and social class may all influence health, none of these is critical to neonatal survival. Although adequacy of the mother's prenatal care may influence the mother's health and therefore the fetus's health, it is not as critical to neonatal survival as is an adequate gestational age and birthweight.

A nurse is caring for an older adult client. Which statement made by the nurse using SBARR indicates "Background"? 1. "All of the client's lab reports are within the normal range." 2. "Tell me what you understood from the instructions I gave you." 3. "I am calling you about the client's predischarge laboratory results." 4. "When I was talking to the client, he told me that he forgot to take vitamin supplement tablets."

1. "All of the client's lab reports are within the normal range." RATIONALE: SBARR stands for Situation, Background, Assessment, Recommendation, and Read back. Statements such as, "All of the client's lab reports are within the normal range" is included in background of SBARR. "Tell me what you understood from the instructions I gave you" is included in read back of SBARR. "I am calling you about the client's predischarge laboratory results" is included in situation of SBARR. "When I was talking to the client, he told me that he forgot to take vitamin supplement tablets" is included in assessment of SBARR.

A nurse is documenting a client's condition and the care provided to the client. Which documentation is correct? Select all that apply. 1. "NPO before surgery." 2. "The physician made a mistake in the record." 3. "I had a good day, and I wish client to have the same." 4. "Late entry - I administered saline to the client at 6 pm." 5. "Removed a diamond ring from the client to enable CT scan."

1. "NPO before surgery." 4. "Late entry - I administered saline to the client at 6 pm." RATIONALE: NPO means nothing by mouth. The client should not take anything orally, before surgery, so this is an important entry that should be included. When making a delayed entry of the client's care, the nurse is correct to specify "late entry" in the record. The nurse should not point out the faults of colleagues, but should ask for clarification. The nurse should avoid generalized phrases or unnecessary statements when documenting a record, but be specific and use complete, concise descriptions of care. The nurse should describe each item removed; a thorough description (rather than "diamond ring") would be a more appropriate in the document.

A client arrives at the prenatal clinic and tells the nurse that she thinks that she is pregnant. The first day of the client's last menstrual period (LMP) was September 14, 2013. Using Naegele's Rule, what date in June 2014 is the client's estimated date of birth (EDB)? Record your answer as a whole number. ________

21 RATIONALE: Add 7 days to the 1st day of the LMP and subtract 3 months.

The nurse concludes that a couple with a newborn with Erb's palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion? 1. "Surgery will correct the palsy." 2. "This is a progressive disorder with no cure." 3. "Recovery usually occurs in about 3 months." 4. "Physical therapy will be necessary for 1 year."

3. "Recovery usually occurs in about 3 months." RATIONALE: The nerves that are stretched take about 3 months to recover from the trauma sustained during birth. Passive range-of-motion exercise and intermittent splinting performed by a trained family member will help facilitate recovery. Only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary. The paralysis is not progressive, and the prognosis usually is excellent. Physical therapy is necessary for about 3 months, not a year.

The licensed practical nurse is supervising the nursing student while charting. Which action of the nursing student may indicate a need for correction? Select all that apply. 1. Charting the care plan with black ink 2. Charting the nursing care in advance 3. Charting the time of an event occurrence 4. Charting retaliatory comments about the client 5. Charting the client's response using generalized phrases

2. Charting the nursing care in advance 4. Charting retaliatory comments about the client 5. Charting the client's response using generalized phrases RATIONALE: Charting of the nursing care must be done after providing the care to the client, not before. The nurse should not chart retaliatory comments about the client because it represents unprofessional behavior. If the information is too generalized, the specific information about the client's status may be overlooked. The charting should be done in only black ink to avoid illegibility. Charting the correct time of an event occurrence indicates appropriate documentation.

While caring for the foot of a client with diabetes, the client tells the nurse of severe pain and pus discharge from the foot. Which format of SOAPE includes this description? 1. Evaluation 2. Assessment 3. Objective information 4. Subjective information

4. Subjective information RATIONALE: Subjective information is what the client states or feels. Evaluation is an appraisal of the response and effectiveness of the plan. Assessment refers to an analysis or potential diagnosis of the cause of the client's problem or need. Objective information is what the nurse can measure or actually describe.

While documenting client records, the nurse finds that an incorrect dose of drug was administered to a client. Which document should be filed in response to this action? 1. Incident report 2. Focus charting form 3. Acuity charting form 4. 24-hour client care record

1. Incident report RATIONALE: An incident report is used to document the details of an unusual event that occurs at the facility, such as administering an incorrect dose of a drug to a client. The focus charting format uses a modified list of nursing diagnosis that involves positive concept of a client's needs. The acuity charting system uses a score to rate the client's based on the severity of the illness. A 24-hour-record keeping system is a consolidated format of documentation of a 24-hour period.

A nurse documents the blood glucose levels before and after the administration of insulin and finds improvement in the client's condition. Which format of SOAPER describes this documentation? 1. Revision 2. Evaluation 3. Assessment 4. Objective information

2. Evaluation RATIONALE: Evaluation is an appraisal of the response and effectiveness of the plan. Revision includes the changes that may be made to the original plan of care. Assessment refers to an analysis or potential diagnosis of the cause of the client's problem or need. Objective information is what the nurse can measure or factually describe.

The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing what with the fetal heart rate? 1. Fetal lie 2. Fetal movement 3. Maternal blood pressure 4. Maternal uterine contractions

2. Fetal movement RATIONALE: In a healthy well-oxygenated fetus, the heart rate increases with fetal movement; there should be an acceleration of 15 beats with fetal movement. Fetal lie is not a part of the evaluation of the fetus in the nonstress test. Maternal blood pressure is not a part of the evaluation of the fetus in the nonstress test. Maternal uterine contractions are used in the contraction stress test.

The registered nurse is explaining recording the chart of a client to a licensed practical nurse (LPN). Which statement made by the LPN indicates a need for further education or discussion? 1. "I will ensure that the chart is clear." 2. "I will ensure that the chart is accurate." 3. "I will ensure that the chart is complete." 4. "I will ensure that the chart is expansive."

4. "I will ensure that the chart is expansive." RATIONALE: The chart used to record the details of the client should be concise to avoid errors. It should be not be expansive because extra information may cause confusion and errors. Recording the chart clearly, accurately, and completely helps to convey the intended message.

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is what? 1. 20 2. 25 3. 30 4. 36

4. 36 RATIONALE: Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% for both arms) and 18% for the chest; thus the total body surface area burned is 36%. Twenty percent, 25%, and 30% are too low.

A primary health-care physician prescribes administration of 25 mg of hydrochlorothiazide to a client, but the nurse accidentally administers 50 mg of the drug, which results in aggravation of the client's condition. Which statements made by the nurse after the incident are true? Select all that apply. 1. "I should monitor client's vitals constantly until the condition is stabilized." 2. "If an incident report is filed, I should admit liability of the cause of incident." 3. "I should report the incident to the primary health-care provider immediately." 4. "I should exclude the details of the health-care provider from the incident report." 5. "An incident report will be filed against me for the mistake against the care of client."

1. "I should monitor client's vitals constantly until the condition is stabilized." 3. "I should report the incident to the primary health-care provider immediately." 5. "An incident report will be filed against me for the mistake against the care of client." RATIONALE: The nurse should monitor the vitals of the client constantly until the condition stabilizes. It is the responsibility of the nurse to report the incident to the primary health-care provider. Incident reports can be filed against this nurse as a charge of negligence. The nurse should not admit the liabilities of the cause of the incident, as it may lead to further legal complications. The details of the primary health-care provider, who is providing the post-incidental care, should be included in the report.

The nurse documents a client's information that leads to nursing malpractice. Which documentation errors made by the nurse may be responsible for malpractice? Select all that apply. 1. Failing to record verbal orders 2. Using permanent black ink pens 3. Charting nursing care in advance 4. Charting the time of event occurred 5. Avoiding judgmental terms while charting

1. Failing to record verbal orders 3. Charting nursing care in advance RATIONALE: The nurse should not fail to record the verbal orders while documenting the reports because all the information should be included in the document. Nursing care should not be documented in advance; it should be recorded after providing the care to the client. Failing to do these activities may lead to a charge of nursing malpractice. The nurse should use only black ink when documenting. The time of event should be documented to ensure that correct guidelines are followed. The nurse should avoid judgmental terms and placing blame when charting.

A client is admitted with a diagnosis of stage 0 cervical cancer (carcinoma in situ). What does the nurse emphasize while helping the client understand her diagnosis and prognosis? 1. Five-year survival rates for this cancer are nearly 100% with early treatment. 2. Radiation therapy is as successful as surgery in the treatment of this type of cancer. 3. Cancer has probably extended into the vaginal wall and may require a radical hysterectomy. 4. Stage 0 indicates that the cancer is invasive and may require surgery in addition to radiation therapy.

1. Five-year survival rates for this cancer are nearly 100% with early treatment. RATIONALE: With carcinoma in situ the epithelium is eroded and replaced by rapidly dividing neoplastic cells. There is no distinct tumor; with treatment the prognosis is excellent. Preinvasive lesions of the cervix are treated with cryotherapy, laser therapy, or loop electrosurgical excision procedure, also known as LEEP. Radiation therapy is used for invasive cervical cancer. Stage II involves the vaginal wall; stage 0 is preinvasive. Stages I to IV are considered invasive by increasing degrees; stage 0 is preinvasive. Treatment is based on the staging.

The registered nurse is explaining about personal health records to a licensed practical nurse. Which statement made by the licensed practical nurse indicates need for further discussion? 1. It may contain only the information submitted by the client. 2. It is managed by various institutions such as private vendors. 3. Vendors may or may not charge a fee for storage of the information. 4. It allows clients to input their own information into an electronic database.

1. It may contain only the information submitted by the client. RATIONALE: The personal health record (PHR) is an extension of the electronic health record (EHR). The PHR does not contain only information submitted by the client but also includes information from other health-care personnel such as pharmacists, laboratories, and the primary health-care provider. The PHR is managed by various institutions such as private vendors. The vendors may or may not charge a fee for storage of the information. The PHR allows clients to input their own information into an electronic database.

Why is it important for the nurse to know the infant's gestational age and how it compares with the birthweight? 1. Potential problems may be identified. 2. Infants lose weight during the first few days of life. 3. Infant's weight must be included on the admission record. 4. Health insurance companies need this information to assign benefits.

1. Potential problems may be identified. RATIONALE: A preterm or small-for-gestational-age (SGA) infant is at risk for problems not seen in the term infant because of immaturity. This information will help the nurse anticipate potential problems and aim interventions at prevention. The infant will lose weight, but the comparison of birthweight and gestational age is important in planning appropriate nursing measures. The information is documented in the infant's record, but this is not the overriding reason for obtaining the data. The health insurance company needs this information, but this is not the overriding reason for obtaining the data.

A nurse caring for a client who presents with herpes zoster conducts extensive research on the disease to formulate the care plan. In addition, the nurse adds photos of the client's infected area to the electronic health record (EHR) to evaluate progress toward recovery. The nurse also educates the client on maintaining proper hygiene to prevent the spread of the infection. Which competencies does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Select all that apply. 1. Using informatics 2. Applying quality improvement 3. Using evidence-based practice 4. Providing patient-centered care 5. Working in an interdisciplinary team

1. Using informatics 3. Using evidence-based practice 4. Providing patient-centered care RATIONALE: According to the Institute of Medicine (IOM) competencies of the twenty-first century, the nurse should use informatics to provide better client care. This involves using information technology to communicate, manage knowledge, reduce errors, and support decision-making. The nurse in the given situation uses informatics to keep track of the client's recovery. A nurse should also use evidence-based practice to improve client care. This includes activities such as conducting research and integrating the best research with clinical practice and client values. The nurse in the given situation displays this competency by conducting extensive research about the client's condition to prepare the care plan. A nurse is required to provide patient-centered care. Relieving pain and suffering, coordinating continuous care, advocating for disease prevention and health promotion, and educating clients are examples of nursing activities related to patient-centered care. The nurse in the given situation performs this task by educating the client about hygiene maintenance.

The practical nurse is discussing the basic rules of documentation with a group of nursing students. Which statements made by a nursing student indicate a need for further discussion? Select all that apply. 1. "I should chart only what I hear, see, and smell." 2. "I should include all my opinions in the document." 3. "I should not indent left margin while documenting." 4. "I should chart before and after I care for the client." 5. "I should use only approved abbreviations while documenting."

2. "I should include all my opinions in the document." 4. "I should chart before and after I care for the client." RATIONALE: The nurse should document only the observation, not opinions. The nurse should chart after providing care to the client. The nurse should chart only what he or she hears, sees, feels, and smells. The nurse should fill all the spaces without empty lines in the document and should not indent left margin while documenting. Only approved abbreviations and medical terms should be used while documenting.

The licensed practical nurse is discussing the various record-keeping forms with a nursing student. Which statement made by the nursing student indicates a need for further teaching? 1. "I should use the Rand system to consolidate the client's orders." 2. "I should mention that I filed an incident report in the client's nursing notes." 3. "I should use the acuity charting system to rate each client by the severity of the illness." 4. "I should use a 24-hour record-keeping system to avoid unnecessary record-keeping forms."

2. "I should mention that I filed an incident report in the client's nursing notes." RATIONALE: The fact that an incident report was filed should not be included in the client's nursing notes. The client's nursing notes include the care plan. The Rand system is used to consolidate the client's orders and needs in a centralized concise way. The acuity charting system uses a score to rate clients based on the severity of their illnesses. A 24-hour record-keeping system helps avoid excess record keeping by obtaining the activities of daily living with 24-hour notations.

A client is admitted to the emergency department with head trauma resulting from an accident. The nurse uses the Glasgow Coma Scale to determine the patient's neurologic function. The patient opens the eyes to painful stimuli, is able to speak but uses inappropriate words,and flexes away from pain. Which number should the nurse use to document the patient's neurological function? 1. 7 2. 9 3. 12 4. 15

2. 9 RATIONALE: The Glasgow Coma Scale is a three-part neurological assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. The patient would receive 2 points for opening eyes to painful stimuli, 3 points for speaking with inappropriate words, and 4 points for flexing away from pain, which totals a GCS score of 9. A rating of 15 indicates that the client is opening the eyes spontaneously, obeying commands, and fully oriented.

While communicating with the primary health-care provider via phone, the nurse wants to repeat the order to ensure better understanding. Which method of communication of SBARR should the nurse choose? 1. Situation 2. Read-back 3. Assessment 4. Recommendation

2. Read-back RATIONALE: SBARR stands for Situation, Background, Assessment, Recommendation, and Read-back. In read-back, the nurse may repeat the order back to the primary health care provider to confirm correct understanding. In situation, the nurse discusses an aspect of the client's care with the primary health-care provider. In assessment, the nurse discusses the previous medication details of the client. In recommendation, the nurse explains her plan of care to the primary health-care provider.

A nurse needs to record a client's data from admission until discharge. Which record will the nurse use? 1. Acuity record 2. Source record 3. Hand-off records 4. Problem-oriented medical record

2. Source record RATIONALE: The nurse will use the source record for writing information from the client's admission until discharge. This record has a separate section for each discipline (such as the admission sheet, nursing records, and medication). Acuity records are not part of a client's medical record. They are useful for determining the hours of care and staff required for a given group of clients. A hand-off record is used when up-to-date information about a client's condition, required care, treatments, medications, services, and any recent or anticipated changes is to be communicated. The problem-oriented medical record (POMR) is a method of documentation that places emphasis on the client's problems. In this record, data is organized by problem or diagnosis.

A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that a client has a prescription for morphine 2 mg intravenously (IV) every 3 hours PRN for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain at a level of 8 on a pain scale of 1 to 10. What is the first thing the covering nurse should do? 1. Determine when the pain medication was last given 2. Verify the pain medication prescription in the clinical record 3. Employ nonpharmacological measures initially to relieve the pain 4. Explain that the primary nurse will be back from lunch in a few minutes

2. Verify the pain medication prescription in the clinical record RATIONALE: Before administering any medication for the first time, the nurse must verify the accuracy of the prescription. The prescription as it appears in the medication administration record is verified against the prescription in the client's medical record. This ensures that the prescription was transcribed accurately. Checking when the pain medication was last given is done after the prescription is verified. Nonpharmacological measures are used for mild to moderate pain, not pain associated with recent major abdominal surgery. The client's pain must be immediately addressed. The covering nurse is capable of verifying the pain medication prescription and administering it safely at the correct time.

The primary health-care provider instructed the nurse to administer 25% dextrose to a client who is diagnosed with hypoglycemia. Which component of SOAPIER should the nurse use to document this information? 1. Revision 2. Evaluation 3. Intervention 4. Assessment

3. Intervention RATIONALE: The nurse should implement the instructions from the primary health-care provider. Intervention of SOAPIER is the specific care given to the client. Therefore, the nurse uses the intervention of SOAPIER to document this information. Revision of SOAPIER documents the changes that may be made to the original plan of care. Evaluation of SOAPIER describes the client's response to the prescribed plan. Assessment of SOAPIER refers to an analysis or potential diagnosis of the cause of the client's problem or need.

A registered nurse is teaching a nursing student about Healthcare Effectiveness Data and Information Set (HEDIS). Which point mentioned by the student post-teaching needs correction? 1. "Healthcare Effectiveness Data and Information Set (HEDIS) is relied upon by health plans throughout the United States as a quality measure." 2. "Healthcare Effectiveness Data and Information Set (HEDIS) is the database of choice for the Centers for Medicare and Medicaid Services (CMS)." 3. "Healthcare Effectiveness Data and Information Set (HEDIS) conducts surveys via a randomly selected sample of adults who were discharged from a hospital between 2 weeks and 6 months ago." 4. "Healthcare Effectiveness Data and Information Set (HEDIS) was created by the National Committee for Quality Assurance (NCQA) to collect data to measure the quality of care and services provided by different health plans."

3. "Healthcare Effectiveness Data and Information Set (HEDIS) conducts surveys via a randomly selected sample of adults who were discharged from a hospital between 2 weeks and 6 months ago." RATIONALE: The Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS) is a survey that is conducted by randomly selecting samples of adults who were discharged from a hospital between 48 hours and six weeks ago, not between 2 weeks and 6 months ago. Healthcare Effectiveness Data and Information Set (HEDIS) is relied upon by health plans throughout the United States as a quality measure. HEDIS is the database of choice for the Centers for Medicare and Medicaid Services (CMS). HEDIS was created by the National Committee for Quality Assurance (NCQA) to collect data to measure the quality of care and services provided by different health plans.

The practical nurse is discussing the filling out of an incident report with a group of nursing students. Which statement made by a nursing student indicates a need for further discussion? 1. "I should give objective information." 2. "I should avoid giving unnecessary details." 3. "I should include the name of the registered nurse in the incident report." 4. "I should avoid mentioning the incident report in the client's nursing note."

3. "I should include the name of the registered nurse in the incident report." RATIONALE: The nurse should include in the incident report the name of the health-care provider notified and the care provided to the client. The nurse should avoid unnecessary details or admitting liability in the incident report, but should include only objective and observed information. The nurse should avoid mentioning the incident report in the client's nursing note because doing so makes it easier for an attorney to request that document for a court case.

The practical nurse is discussing with the group of nursing students the guidelines for safe computer documentation. Which statements made by the nursing students indicates the need for further discussion? Select all that apply. 1"I should protect the computerized printouts." 2. "I should follow the correct protocol for correcting errors." 3. "I should share the password with another caregiver in my absence." 4. "I should follow the agency's confidentiality procedure for documentation." 5. "I should leave the information about the client displayed for another caregiver to see."

3. "I should share the password with another caregiver in my absence." 5. "I should leave the information about the client displayed for another caregiver to see." RATIONALE: The nurse should not ever share their password with another caregiver because this prevents unauthorized access and tampering with records. The nurse should not leave the information about the client displayed on a monitor where others have the opportunity to see it. The nurse should protect computerized printouts. The nurse should follow the correct protocol for correcting errors. The nurse should follow the agency's confidentiality procedure for documentation.

The nurse is caring for an older adult client who is aphasic. The client's family reports to the nurse manager that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure intake and output. What should the nurse manager consider before responding? 1. Procedures for a client's benefit do not require a signed consent. 2. Clients who are aphasic are incapable of signing an informed consent. 3. A separate signed informed consent for routine treatments is unnecessary. 4. A specific intervention without a client's signed consent is an invasion of rights.

3. A separate signed informed consent for routine treatments is unnecessary. RATIONALE: This is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

While documenting a client's reports, the nurse documents that the client feels drowsy after taking medication. Which part of SBAR communication technique is the nurse referring to? 1. Situation 2. Read-back 3. Assessment 4. Background

3. Assessment RATIONALE: The assessment part of SBAR includes the information about the client, whether the medications are working properly, and whether the client is taking medications on time. Determining what is happening with the client is the situation (in this case, client feeling drowsy is the situation). Read-back includes reading the order back to the physician. Background includes the laboratory results or any test results of the client.

While reporting the laboratory results of a client to a health-care provider, the nurse states, "The client's laboratory reports are within the normal limits." Which part of SBARR technique does the nurse refer to? 1. Situation 2. Read back 3. Background 4. Recommendation

3. Background RATIONALE: Documenting the laboratory values of a client refers to "background" in SBAR (Situation, Background, Assessment and Recommendation). "Situation" determines what is going on with a particular situation. "Recommendation" refers to requesting an order for the client to treat the condition. "Read back" refers to the extra "R" in SBARR and includes reading the order back to the physician.

A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing? 1. Flight of ideas 2. Idea of reference 3. Delusion of grandeur 4. Auditory hallucination

3. Delusion of grandeur RATIONALE: A delusion of grandeur is a fixed false belief that the person is a powerful, important person. A flight of ideas is an increase in the speed of thinking causing the person to shift from one idea to another without completing the previous idea; it is often expressed with pressured speech. An idea of reference is an incorrect interpretation of an external event as having a special meaning to the person. An auditory hallucination is experienced when a person hears voices without external stimuli.

A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates an understanding? 1. "Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." 2. "Blood enters the heart from the inferior vena cava; it then flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." 3. "Blood enters the heart from the aorta, flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricle, and finally exits through the superior vena cava." 4. "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."

4. "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta." RATIONALE: Stating that blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta correctly describes the flow of blood through the heart after birth. The ductus arteriosis is a fetal structure that is not present in the adult heart. Blood enters the right side of the heart via the inferior and superior vena cava; blood flows from the right atrium, to the right ventricle, to the lungs, and then to the left atrium. Blood exits, not enters, the heart from the aorta.

The licensed practical nurse is discussing with a nursing student the instructions to be followed while documenting. Which statement made by the nursing student indicates the need for further discussion? Select all that apply. 1. "I should avoid charting for someone else." 2. "I should use black ink when using handwritten records." 3. "I should avoid rushing to complete the charting of information." 4. "I should leave blank spaces between each line of documentation." 5. "I should apply correction fluid to correct errors while documenting."

4. "I should leave blank spaces between each line of documentation." 5. "I should apply correction fluid to correct errors while documenting." RATIONALE: The blank spaces while documenting should be eliminated to avoid the insertion of additional or incorrect information by another person. While documenting, the application of correction fluid should be avoided because it may lead to illegibility of charting and can be perceived as hiding information. Charting for someone else should be avoided because one is accountable for the information that is documented. Black ink while documenting provides legibility. Avoiding rushing decreases the possibility of errors.

A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. How does this nurse understand that the edema should be documented? 1. 1+ 2. 2+ 3. 3+ 4. 4+

4. 4+ RATIONALE: Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2+ indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.

A nitrazine test strip that turns deep blue indicates that the fluid being tested has what pH? 1. 4.5 2. 5.5 3. 6.5 4. 7.5

4. 7.5 RATIONALE: Amniotic fluid changes the color of a nitrazine stripfrom yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5 or 6.5 would result in a test strip of yellow, olive-yellow or blue green, respectively.

The nurse caring for a client approaches the primary health-care provider and asks about adding medication and modifying the client's discharge summary. Which element of communication addressed by SBARR is the nurse implementing? 1. Situation 2. Read-back 3. Assessment 4. Recommendation

4. Recommendation RATIONALE: SBARR (Situation, Background, Assessment, Recommendation, and Read-back) is a method of communication among health care workers. It is considered a safety measure in preventing errors caused by poor communication. The nurse utilizes the recommendation aspect of SBARR by suggesting adding a medication to a client's discharge summary. "Situation" may deal with conditions in which the nurse explains the client's condition to the primary health care provider. Read-back is a method of confirming the given information to make sure that the client's details are not misunderstood. Assessment is a method of drawing information from the client from the provided details.

While caring for a client with an infection, the nurse notices that the client is not responding to the medications and documents the changes to be made to the original plan of care. Which charting format is appropriate to document these changes? 1. PIE 2. SBAR 3. SOAPE 4. SOAPIER

4. SOAPIER RATIONALE: SOAPIER includes a revision section that includes the changes that may be made to the original plan of care. This revision is mainly done if the client does not respond to the medications or the plan of care is inappropriate to the client. The PIE (Problem, Intervention, and Evaluation) format is used by the nurse to assess all the areas to compare the results with normal standards. SBAR is a part of the documentation and the method of communication among the health care workers that includes situation, background, assessment, recommendation but not a revision. SBAR helps in preventing errors from poor communication during "hand-off" or "handover" interactions. SOAPE is the documentation format that includes subjective and objective information, assessment, plan of care and evaluation. It is the organized format to record client information.

The licensed practical nurse advises a nursing student to avoid leaving empty blanks in the client record. What is the rationale behind this suggestion? 1. To make the chart reliable 2. To make the information accountable 3. To prevent the chart from becoming illegible 4. To avoid the addition of incorrect information.

4. To avoid the addition of incorrect information. RATIONALE: To prevent the addition of incorrect information, the nurse should avoid leaving blank spaces in the record. To make the chart more reliable, the nurse should record all facts in the client record. To avoid the chart becoming illegible, the nurse should not erase, apply correction fluid, or scratch the errors in the record. Preparing the chart by oneself makes the information more accountable.