NUR20020- Fundamentals NCLEX Practice Questions Ch. 15

The nurse is calculating the intake of the client's lunch tray. The client drank 4 ounces of juice, 6 ounces of water and 8 ounces of coffee. The correct entry on the intake and output record is: a.) 18 ounces b.) 1080 ml c.) 10 ounces d.) 270 ml e.) 540 ml

Answer: E 540 ml

After teaching a group of nursing students about the medical record and its purposes, the instructor determines that the group needs additional instruction when the students state which of the following? a.) "The medical record provides valuable information about a client's assessment." b.) "The record provides a means for decisions about reimbursement for care." c.) "Medical records are primarily used for communication among nurses and physicians." d.) "The medical record can serve as a resource for conducting research."

Answer: C Medical records provide a means of communication for all healthcare team members involved in the client's care, not just nurses and physicians.

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report? a.) client's intake for previous meal b.) client's admission number c.) client's current assessment d.) client's family members

Answer: C The nurse should include the current assessment of the client in the verbal handoff summary because it enables the receiving nurse to prepare for the client before arrival and to clarify any information that may appear on the written handoff form.

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do? a.) erase the erroneous entry b.) write over the error after using correction fluid c.) strike out with a single line and place initials d.) overwrite the erroneous entry

Answer: C The nurse should strike out the erroneous entry with a single line and place initials over it.

A nurse working as part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team's agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? a.) FOCUS data, action, and response note b.) problem, intervention, and evaluation note c.) charting by exception d.) narritive notes

Answer: C The team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation.

A nurse is caring for a client with bronchitis and phones the laboratory for the results of the client's sputum culture. Which of the following would be least appropriate to include when communicating with the laboratory? a.) the client's identification number b.) name of client's physician c.) client's diagnosis d.) time the specimen was ordered

Answer: D When communicating with other departments such as the laboratory, the nurse should identify any pertinent client identification numbers, the client's diagnosis, and the attending physician to ensure accuracy in the client identification. The time that the specimen was ordered is not important.

A nurse is making a home visit to a client for the first time. The nurse is documenting assessment information on a laptop computer as each aspect of the assessment is completed. The nurse is using which of the following? a.) Batch Charting b.) Computerized Provider Order Entry c.) Computer-based Personal Record d.) Point of Care Documentation

Answer: D Point of Care Documentation The nurse is using point of care documentation, documentation that takes place as the care occurs. Computerized provider order entry (CPOE) involves the use of remote computer access in which providers can enter orders when they are offsite. The universal computer-based personal record (CPR) is designed to bring together all health data on a single patient into a readily accessed form. Batch charting refers to documentation of events on several clients at the end of the shift.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which of the following would be entitled to access of the client's records? a.) those directly involved in the client's care b.) any family member of the client c.) close friends of the client d.) healthcare professionals of the facility

Answer: A Only those directly involved in client care are entitled to access the client's information.

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the nursing assistant failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. Which of the following would be most appropriate for the nurse to do? a.) include time and date of the incident on the form b.) attach a copy of the incident report to client's records c.) hilight the incident in the client's records as involving an error d.) mention the name of the nursing assistant in the client's records

Answer: A The nurse should include the date and time of the incident in the incident report, the events leading up to it, the client's response, and a full nursing assessment.

A nurse is working as part of a team that is presenting an in-service to the staff on the TeamSTEPPS program. Which skills would the nurse expect to be addressed as part of this program? Select all that apply. a.) Team Leadership b.) Communication c.) Flowchart Development d.) Situational Monitoring e.) Mutual Support f.) Checklist Completion

Answer: A, B, D, E The TeamSTEPPS program involves four teachable-learnable skills: team leadership, situational monitoring, mutual support, and communication. Checklist completion and flowchart development are not addressed.

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? a.) written plan of care b.) intervention carried out c.) multidisciplinary interventions d.) client assessment

Answer: B In the PIE notes, the nurse documents the problem, intervention and evaluation.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the healthcare provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the healthcare provider? a.) SOAP b.) SBAR c.) CBE d.) EMAR

Answer: B The nurse should use SBAR to communicate verbally to the healthcare provider. Situation, Background, Assessment, and Recommendation (SBAR) is the communication tool to provide critical client information to the healthcare provider.

A nurse is preparing to document care provided to a client. Which of the following would be most appropriate for the nurse to do to ensure that the documentation is concise? a.) refer to the client by name each time b.) use phrases in narratives c.) offer interpretations of any described behaviors d.) use abbreviations whenever possible

Answer: B To ensure that documentation is concise, the nurse should use partial sentences and phrases in narratives.

The following information appears on a client's medical record: Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area. When documenting this information using the SOAP method, which of the following would the nurse document as "S"? a.) abdomen distended b.) "I have a fair amount of pain in my belly near my incision." c.) administer oxycodone 5mg as ordered d.) client lying on side with legs drawn up

Answer: B When using SOAP notes, the client's statement would be documented as "S"

A nurse is preparing to document information about a client using the FOCUS system. Which information would the nurse record in the action section? a.) subjective data b.) interventions c.) objective data d.) effect of action on client

Answer: B When using the FOCUS system, information is organized by data (D), action (A), and response (R). The data portion of the statement describes subjective and objective data that support the focus of the note. Interventions and treatments are included in the action section of the note, whereas the patient's response to therapy is discussed in the response section.

A newly hired nurse is participating in the orientation program for the healthcare facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as information to be recorded on the first line? a.) data, action, and response b.) problem addressed c.) plan of care d.) nursing activities during a shift

Answer: B Problem Addressed The SOAP notes first line identifies the problem being addressed.