The Nursing Process and Documentation

The nurse is preparing to reinforce teaching with a patient about medications. Which finding would cause the nurse to proceed with the teaching session?

Patient has just finished going to the bathroom.

Which patient finding would the nurse report as subjective data?

Patient has stomach cramps. Information that is known only to the patient and family members is subjective data. Examples of subjective data include nausea, pain, anxiety, fear, depression, and discouragement.

ADPIE - Nursing Process

An easy way to remember the first letter of each step of the nursing process is to use the mnemonic ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Which expected outcome would the nurse most likely observe written in a patient's care plan?

Patient will rate pain level at a 2 or below by discharge. This meets all the requirements for a correctly written goal: (1) a realistic, specific action to be taken by the patient; (2) an action that the patient is willing and able to perform; (3) an action that is measurable; and (4) a definite time frame.

Which information that the nurse gives in report is objective?

Patient's blood pressure is 120/70. Blood pressure is objective data. Objective data are those things that the nurse can observe through the senses of hearing, sight, smell, and touch.

Percussion

Percussion is using tapping movements to detect abnormalities of the internal organs.

The nurse is caring for a patient with heart problems. Which actions should the nurse take during the assessment step of the nursing process? Select all that apply.

Performs a focused heart examination Reviews results of a complete blood count Auscultates heart tones

A patient has a fever. Which independent intervention can the nurse implement?

Place a cool washcloth on the patient's forehead.

The LPN/LVN is assisting the RN who is writing long- and short-term goals. Which step of the nursing process are the nurses working on?

Planning

The following goal is written in a patient's care plan: Patient will verbalize three foods allowed on a heart-healthy diet. Which action should the nurse take to evaluate this goal?

Ask the patient to list items that will be eaten after discharge.

The nurse is interviewing a patient about nausea. The patient constantly talks about the possible causes of the nausea. Which response should the nurse make?

Ask, "What have you tried to relieve the nausea?"

Place the steps of the nursing process in order.

Assessment Diagnosis Planing Implementation Evaluation

Assessment

Assessment is the gathering of information through signs and symptoms, patient history, and both subjective and objective findings.

The nurse listens to a patient's abdomen with a stethoscope and hears active bowel sounds. Which physical assessment technique did the nurse use?

Auscultation

Auscultation

Auscultation is listening for abnormal sounds in the lungs, heart, or bowels.

Planning is the process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem

Planning is the process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem

The nurse changes a dressing and observes a patient's wound has decreased in size. Where in a problem-oriented medical record would the nurse chart this information?

Progress notes Progress notes are the section the nurse would chart nursing care and findings that relate to the problem list.

According to this "pocket brain" (see image), which action should the nurse perform at noon?

Turn the patient

The nurse is caring for a resident in a long-term care facility. Which action should the nurse take when charting care about this resident

Use a specific time for each entry.

The nurse is caring for a resident in a long-term care facility. Which action should the nurse take when charting care about this resident?

Use a specific time for each entry. Each entry should have a specific time and be in chronological order.

The nurse observes a patient pacing and believes the patient is anxious. Which initial action should the nurse take?

Validate findings with the patient. Nurses who use critical thinking avoid jumping to conclusions about patients or patient care. They also avoid making decisions based on assumptions. They validate, or ensure the correctness of, the information they obtain.

The nurse needs to verify a patient's oxygen saturation level. Where in a source-oriented chart would the nurse look?

Vital signs form

A patient's spouse asks to see the patient's chart. Which response by the nurse is best?

"I will need to have written permission from the patient first."

test taking tips

A general guideline to remember about assigning tasks is that activities of daily living can be delegated. Activities of daily living include bathing, oral care, I&O, toileting, eating, and hygiene needs. Nursing decisions cannot be delegated, such as changes in patient's/resident's condition. Thus the nurse would not delegate charting a headache with nausea.

Which situations will cause the nurse to complete an incident report? Select all that apply

A patient fell during ambulation. A visitor fainted in the lobby. A new medication was ordered 2 days ago and is just being administered now. A patient spilled hot coffee on the chest.

Which situations will cause the nurse to complete an incident report? Select all that apply.

A patient fell during ambulation. A visitor fainted in the lobby. A new medication was ordered 2 days ago and is just being administered now. A patient spilled hot coffee on the chest.

Which action should the nurse take when completing a variance report for a patient who fell out of bed?

Add that x-rays were taken of the hip. Incident/variance forms will include not only the incident but also the action taken and any care provided after the occurrence.

Test taking tips

Because the nurse walked the patient, this is implementation. Implementation is what the nurse does for the patient. If the answer was assessment, the question would have focused on gathering information about the gas buildup. If the answer was planning, the question would have focused on goals and choosing interventions for the gas buildup. If the answer was evaluation, the question would have focused on asking the patient if the walking helped eliminate the gas buildup.

The nurse is using DAR charting. Which information would the nurse chart after the A for a patient with food poisoning?

Bedside commode placed near bed This would be charted after the A for action

Which action by the LPN/LVN indicates a correct understanding of the LPN's/LVN's role in the nursing process?

Carries out interventions

Which actions indicate the nurse understands narrative charting? Select all that apply.

Charts in chronological order Charts from admission to discharge Charts concisely and succinctly

Concept Maps

Concept maps, also known as mind maps, can be used to diagram and connect data about any subject. It uses rectangles, triangles, and circles. They also can be used to organize and plan nursing care, in effect making them a care plan as well.

Critical pathway

Critical pathways, also called clinical pathways, are similar to standardized care plans except that they are based on the progression expected for each day the patient is in the hospital. Certain nursing interventions are provided each day, and they change as the patient improves and requires less comprehensive nursing care.

DAR charting.

Data=collecting data about the problem Action=completed about he problem Response= to the problem

Which phrase should the nurse use to describe the nursing process?

Decision-making framework The nursing process is a decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them.

The LPN/LVN reviews a patient's care plan. Which nursing diagnosis is the priority?

Deficient fluid volume Fluid is a physiological need and is the first level of survival according to Maslow.

Which action by the nurse indicates compliance with the Health Insurance Portability and Accountability Act (HIPAA)?

Destroys handwritten notes about the patient's care Any handwritten notes or copies of confidential patient information should be shredded once their purpose has been fulfilled.

The LPN/LVN is collecting data from a patient by performing an interview. Which action should the nurse take first?

Develop rapport When the nurse enters a patient's room or area to perform a nursing interview, it is important to first establish rapport, creating a relationship of mutual trust and understanding.

The LPN/LVN is working in home health. Which action should the nurse take?

Document how the patient is progressing in follow-up visits. LPNs/LVNs can make subsequent visits, and it is important to show in the documentation how the patient is making progress toward specific goals

Which documentation practices can increase the nurse's chance of malpractice? Select all that apply.

Documents a change in respirations but does not document a change in blood pressure Charts information on Mary B. Smith's chart that occurred with Mary A. Smith Forgets to inform the health-care provider that the patient was bit by a tick while camping Does not transcribe the order for supplemental oxygen

The LPN/LVN reviews the nursing diagnosis written on the care plan: Risk for infection related to a break in the skin. The italicized phrase represents which component of the nursing diagnosis?

Etiology The etiology refers to the causative factor(s) and is connected to the diagnostic label by the words "related to."

Evaluation

Evaluation is performed when the nurse reflects on the interventions he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step.is performed when the nurse reflects on the interventions he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step.

Which actions should the nurse take before suctioning a patient who is having problems swallowing? Select all that apply.

Gather supplies for the procedure. Explain the procedure to the patient.

The LPN/LVN is working in a long-term care facility. Which findings can the LPN/LVN allow the unlicensed assistive personnel (UAP) to document? Select all that apply.

Gave complete bath at 0800 today Resident's total intake was 875 mL Resident had two bowel movements Resident ate 80% of breakfast and 75% of lunch.

Not Charting

If something is not charted, then it was not done. Period. However, this is inherently false if the documentation method is charting by exception, which limits charting to only abnormal findings, situations, conditions, or results.

The nurse ambulates a patient with intestinal gas buildup in the hallway to help relieve the discomfort. Which step of the nursing process did the nurse complete?

Implementation

Implementation

Implementation is the process of taking actions to resolve the patient's problems, the nursing diagnoses. These actions are also called interventions. When the nurse performs these interventions, it is called implementation.

The nurse is providing care to a patient with urinary retention (problems urinating). Which dependent interventions might the nurse expect to perform? Select all that apply.

Insert a Foley catheter. Administer a diuretic. Obtain a clean-catch urine sample.

Inspection

Inspection is the visual examination of the patient's body for rashes; breaks in the skin; and normal appearance of eyes, ears, nose, mouth, limbs, and genitals.

Which tasks should the nurse perform based upon the information listed in the Kardex (see image)? Select all that apply.

Keep siderails ×2 up constantly Assist with feeding Change the abdominal dressing daily

Evaluate the nurses notes below (see image). Which finding could cause the nurse legal issues?

Left a blank space in the nurse's notes The nurse did leave a blank space in the 1420 entry. Avoid leaving a blank line, or even a blank portion of a line. Blank lines serve as an invitation for another individual to write something in the middle of the nurse's charting that could be attributed to the nurse.

Which is an appropriate action for the nurse to take when computer charting?

Log off immediately after charting patient information

he LPN/LVN is assisting the RN in completing a weekly assessment data form. In which area are the nurses working?

Long-term care facility Because the long-term care facility is the home of the resident, some additional data are collected and documented in the weekly assessments, along with the typical data found in a more traditional acute care assessment.

The nurse writes the following in a patient's chart: Heart tones strong. However, the nurse meant to write weak rather than strong. What should the nurse do?

Make a single horizontal line through strong and initial it.

Which statement by the nurse indicates a correct understanding of charting?

My charting can be used against me in a court of law."

Palpation

Palpation is touching or feeling the torso and limbs for pulses, abnormal lumps, temperature, moisture, and vibrations.

The nurse is reinforcing teaching to nursing students about the purposes of documentation. Which information should the nurse include? Select all that apply.

Provides continuity of care Obtains reimbursement for care Serves as a record for quality assurance Serves as a legal record

Which safety measures should the nurse take during implementation? Select all that apply.

Read the patient's armband and ask the patient to state name and birthdate. Refer to facility procedures if unsure about a skill. Continue to observe the patient for any problems.

The nurse is using SOAP to chart patient care. Which information would the nurse place after the S?

Reports, "Hard to catch breath when I take a deep breath."

Which chart entry would the nurse document in a patient's chart?

Right abdominal dressing dry and intact.

SOAP

S stands for subjective data. O for objective data. A for Assessment. P for plan.

The nurse spills coffee on a patient's chart while charting. Which action should the nurse take?

Shred the damaged page after notes are recopied word for word. Make a notation on the damaged page indicating the portion of the page that will be rewritten and make reference to the recopied page ("Recopied to page 3"). Then, on the new blank page, write "Recopied from page 2" and include the current date and time and signature.

Which charting entry best reflects the nurse's evaluation of patient learning for constipation?

States, "I will eat more high-fiber foods"

multidisciplinary care plan

The multidisciplinary care plan includes choices of different nursing diagnoses with options the nurse may select in order to individualize the patient's care. In addition, the multidisciplinary care plan contains similar areas for respiratory therapists, social services workers, physical therapists, and dietitians to document their plans and the patient's response in the electronic health record.

test taking tip

To figure military time for p.m., add 1200 to the time. For example, 7:30 p.m. (1200 + 730 = 1930). For 6:15 (1200 + 615 = 1815).

Test taking tips

When answering questions about charting, remember the more descriptive and objective the charting entry is, the better. Another consideration is correct use of abbreviations. Using these suggestions, the nursing student can eliminate the wrong answers: the answers with cc and MS (abbreviations that should not be used) and the answer with the word well (well is subjective and not descriptive or objective).

Test taking tip

When the nursing student sees HIPAA, the student should think confidentiality, and that will lead the student to the correct answer. Talking to the nephew and leaving the chart open at the desk do not describe confidentiality and can be eliminated as correct answers.

The nurse is contributing data to the care plan from a primary source. Which source did the nurse use?

When the patient provides information, it is considered primary data.