Fundamentals of Nursing - Ch. 16 questions

The student nurse is reviewing physician orders written on a patient's chart. Which entry is written incorrectly because it is on the "do not use" list of the JCAHO? A. Tylenol 650 mg po every 4 hours for fever greater than 102 degrees F B. Synthroid 0.125 po daily C. Epogen 6500 U SQ daily D. Valium 5mg po on-call to the OR

C

In many institutions, which of the following telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner? A. Orders for dianostic studies B. Orders for dietary changes C. Orders for respiratory treatments D. Orders for antibiotics

D

Which of the following clinical situations is addressed by the provisions of HIPAA? A. A patient has asked a nurse if he can read the documentation that his physician wrote in his chart B. A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer C. A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test D. A patient who resides in Indiana has required hospitalization during a vacation in Hawaii

A

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnoses with multiple sclerosis and their families. Providing this information is an example of which of the following? A. a referral B. Reporting C. A consultation D. Conferring

A

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurse document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? A. Charting by exception B. Problem, Intervention, Evaluation (PIE) charting C. Focus charting D. Variance charting

A

A patient's diagnosis of pneumonia requires treatment with antibiotics. The corresponging order in the patient's chart should be written as: A. Avelox 400mg daily B. Avelox 400mg qd C. Avelox 400mg OD D. Avelox 400mg Q.D.

A

The nurse is documenting a variance that has occured during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially intiate in-service programs. This is an example of which type of report? A. Incident report B. Telemedicine report C. Transfer report D. Nurse's shift report

A

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record patient conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A. Narrative notes B. SOAP notes C. Charting by exception D. Focus charting

A

Which example may illustrate a breach of confidentiality and security of patient information? A. The nurse provides information over the phone to the patient's family member who lives in a neighboring state B. The nurse provides information to a professional caregiver involved in the care of the patient C. The nurse accesses patient information on the computer at the nurse's station then logs off before answering a patient's call bell D. The nurse informs a colleague that she should not be discussing patient information in the hospital cafeteria

A

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of: A. electronic medical records B. nursing informatics C. computerized documentation D. telemedicine

B

It is acceptable for the nurse to accept a verbal order from the physician in which of these situations? A. Prior to the patient leaving the floor for therapy B. During a medical emergency C. Immediately prior to discharge D. Upon admission of the patient to the unit

B

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours? A. Acuity charting forms B. A graphic sheet C. 24-hour fluid balance record D. Medication record

B

A nurse on a night shift entered an elderly patient's room during a scheduled check and discoverd the patient down on the floor beside her bed after falling when trying to ambulate to the washroom. After assesing the patient and assisting her back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? A. Gauging the nurse's professional performance over time B. Protecting the nurse and the hospital from litigation C. Identifying risks and ensuring future safety for patients D. Following up the incident with other members of the care team

C

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? A. "Patient is guarding her abdomen and occasionally moaning" B. "Patient has a history of recent abdominal pain" C. "2mg Dilaudid PO administered with good effect" D. "Patient complaining of abdominal pain rated at 8/10"

D

According to HIPAA passed in 1996, patients: A. need to obtain legal representation to update their health records B. can be punished for violating guidelines C. are required to obtain health record information through their insurance company D. have the right to copy their health records

D

The nurse has paged a patient's primary care physician in response to the patient's low blood pressure reading. When returning the nurse's page, the physician has asked the nurse to temporarily hold the patient's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order? A. Record the order verbatim in the patient's chart and follow it with the nurse's printed name and signature alone B. Write out the order, the physician's name, the nurse's name, and the name of a witness C. Obtain confirmation of the order from a physician or nurse practitioner present on the unit D. Write "T.O." after the order and write out the physician's name and the nurse's name

D

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations? A. When reporting to a patient's family member or significant other B. When documenting the care that was provided toa patient whose condition recently deteriorated C. When providing a change-of-shift report to a colleague D. When communicating a patient's change in condition to the patient's physician

D

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the follwoing drawbacks? A. Failure to identify and record patient problems and associated interventions B. Increased workload for nurses in order to complete necessary documentation C. Significant differences in the charting between nurses due to lack of standardization D. Vulnerability to legal liability since nurse's safe, routing care is not recorded

D

When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A. using only abbreviations whose meaning is self-evident to an educated health professional B. using only those abbreviations that are defined in full at another location in the patient's chart C. ensuring that abbreviations are understandable to patients who may seek access to their health records D. limiting abbreviations to those approved for use by the institution

D

When taking a telephone order from a physician, the nurse verifies that he/she understands the order by: A. faxing the written order to the physician's office B. asking the physician to summarize the orders given C. confirming the order with the nurse manager D. repeating the order back to the physician

D