Clinical Decision Making, Communication, Evidence-Based Practice NUR 111 Study Guide Test 1

The nurse manager is mediating a conflict between two staff members. Which communication style is most appropriate for the nurse manager to use in this situation? A. Assertive Communication B. Aggressive Communication C. Therapeutic Communication D. Passive Communication

A Assertive communication is used to declare and affirm opinions and respect the rights of others to communicate in the same fashion. The assertive communicator strikes a balance between the aggressive communicator and the passive communicator. It is the assertive communicator who has the most productive communication with others.

The nurse is communicating with the physician about an order that is causing the client to lose sleep at night. The client's condition has improved, and the nurse questions the need for continued close monitoring. The physician makes a derogatory remark about the client and insists that the order be carried out. The nurse responds "Yes, doctor" and reports back to the client. What could be the result of this exchange between the physician and nurse for the client? A. The client's progress may be compromised B. The client will feel secure C. The client will not have a response D. The client will feel respected

A By taking the passive stance, the nurse has not acted as the client's advocate, which could impact the client's positive progress in the healing process.

A new nurse asks what the primary difference is between an end of shift report and a hand-off communication. What is the best response by the seasoned nurse? A. "Every end of shift report is a hand-off communication." B. "The end of shift report occurs when a client is transferred to another unit." C. "The hand-off communication only occurs at discharge." D. "The end of shift report is not required, hand-off communication is required."

A Handoff is defined as "the transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm." End of shift report and hand-off communication are both required. An end of shift report occurs at the end of a nursing shift when care is being transferred to another nurse.

When performing a literature review for evidence, nurses look for scientific elements in the journal articles, including all except: A. Names of patients involved in the data collection B. The abstract C. A written conclusion D. An overview of the study conducted

A Looking for clinical evidence from research sources usually includes a review of the pertinent literature. When doing a literature review for evidence, nurses look for scientific elements in the journal article including the abstract, an overview or summary of the study conducted, a written conclusion.

A nurse is working on a psychiatric lock-down unit and is preparing to start shift duties. The off-going shift remains on the floor to maintain the safety of the clients. Which type of reporting might this unit use? A. Tape-recorded report B. In the client room reporting C. Face-to-face report D. Nursing rounds reporting

A The advantage of the previous shift staying while the upcoming shift listens to a taped report is that the clients are monitored during the report and problems can be addressed immediately. Also, if an oncoming nurse has a question, it can be addressed with the off-going nurse after the report.

The nurse is preparing to give care to a dying client whose family is at the bedside. Which facial expression is most appropriate for the nurse to use in this situation? A. Warmth and concern B. Mouth turned down with the head tilted back C. No obvious expression D. Smiles to lift the family's spirits

A The appropriate expression would include an expression that conveys genuine concern for the family and client.

The nurse is conducting an assessment on a client who has limited English speaking skills. The client asks the nurse to speak slowly so the client can better understand the nurse's questions. Which intervention is also appropriate for the nurse to include in this client's plan of care? A. Speaking directly to the client B. Using technical medical terms C. Using words in the client's jargon D. Asking the family to interpret words the client does not understand

A The client with limited English skills needs the nurse to speak normally and directly. This demonstrates respect and allows the nurse the opportunity to assess the impact of the message on the client.

A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of his pain on a 0 to 10 scale. She also should have asked about the characteristics of his pain and assessed for any changes that might have contributed to worsening of the pain.

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hrs. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.

A The nurse should collect further data on the client to determine why he has not achieved satisfactory pain relief, because various factors might be interfering with his comfort. The nursing process repeats in an ongoing manner across the span of client care.

A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. "I will review the past medical history on the client's record to get more information." C. " I will go carry out the new prescriptions from the provider." D. " I will ask the client if his nausea has resolved."

A The nurse should prioritize client problems during the planning step of the nursing process.

To provide optimized individual clinical care to clients, the nurse understands that the components of evidence-based care include all except: A. Managerial expertise B. Client perspectives C. Current strong evidence D. Clinical expertise

A To provide optimized individual clinical care to clients, nurses use three components that provide the framework for evidence-based practice: current strong evidence, client perspectives, and clinical expertise.

The nurse is caring for a client who continues to develop pressure sores despite the trial and error measures the nurses have taken to protect the client's skin. What can the nurse do to provide evidence-based care? A. Incorporate research to improve client's outcome B. Mandate the client change his own dressing C. Call the physician for advice on wound care D. Use the most expensive wound care supplies to improve client's outcome

A Trial and error is a means of attempting to gain knowledge. It is not systematic or scientific approach to the problem. Evidence-based nursing is based on research to improved client outcomes.

Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply.) A. Use an open posture B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Respond positively when giving feedback.

A, C, E Having an open posture, facing the client, and leaning forward are ways the nurse can demonstrate active listening. Establishing and maintaining eye contact are ways the nurse can demonstrate active listening. Responding positively when giving feedback is a way the nurse can demonstrate active listening.

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "He said he hurts after walking about 10 minutes." C. Pain rating is 3 on a scale of 0 to 10. D. Skin is pink, warm, and dry. E. The assistive personnel reports the client walked with a limp.

A, D, E Objective data includes information the nurse measures, such as vital signs. Objective data includes information the nurse observes, such as skin appearance. Objective data includes information on observations of others, such as family and staff.

The student nurse is caring for a client with Parkinson's disease and has determined the goals to concentrate on working to improve fine motor skills, especially for completing activities of daily living. Which would be considered a collaborative intervention? A. Provide assistive devices and educate client to use a grab bar and large-handled utensils. B. Provide assistance as needed with dressing and grooming. C. Make sure lighting and space are adequate for client. D. Administer medications to improve muscle tone.

A. Collaborative interventions are actions the nurse carries out with other health team members such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel.

A nursing diagnosis of fluid volume deficit is related to active fluid loss, secondary to diarrhea, has been formulated for a client. Which would be an appropriately written goal statement for this diagnosis? A. Client will have intake of at least 1000mL within 24 hours. B. Client will have good skin turgor. C. Client will drink more fluids by tomorrow. D. Client will have moist mucous membranes.

A. The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress.

When formulating the plan of care for a new admission, the nurse recognizes that evidence-based practice is most helpful to the nurse when: A. Collecting data regarding the client's current medications B. Evaluating the client's outcomes of care C. Determining the client's dietary needs D. The nurse determines the client's nursing diagnoses

B A goal of evidence-based practice is to improve client care, and the best way to justify care is by evaluating the client's response to care by examining outcomes.

Which nursing behavior demonstrates the use of appropriate therapeutic listening skills? A. Sitting on the bed next to the client B. Absorbing both the content and the feeling the client is conveying C. Presuming an understanding of the client's needs D. Reacting quickly to the client's message

B Absorbing the content and feeling of the client's message is a therapeutic listening technique.

What behavior is often expected when communicating with a nurse with an assertive communication style? A. Blaming others B. Acknowledging emotion C. Avoiding arguments D. Denying anger

B Assertive communicators are those who declare and affirm their opinions. This type of communicator will acknowledge the emotions of others.

The nurse is teaching a client and family about care that will be required after the client has been discharged. The client questions the nurse's teaching and the nurse proceeds to explain the rationale behind the teaching activities. The assertive nurse expects which response by the client and family? A. Resentment B. Increase compliance C. Anger D. Feelings of victimization

B Assertive communicators expect that the client would be compliant after rationales have been explained.

A nurse preceptor explains to a graduate nurse that the hospital uses evidence-based practice (EBP) because: A. Care cannot be given unless it is backed by research B. EBP provides credibility to the profession C. EBP assists in the evaluation of nurses' performance D. EBP helps determine the client's preferences of care

B Evidence-based care provides credibility for the profession because the profession can demonstrate through research that client outcomes are positive.

A client who is hard of hearing is preparing to be discharged from the hospital after being diagnosed with lupus erythematosis. The nurse has completed teaching for the client and has also prepared written instructions for the client to reinforce the teaching. What is the next step of priority for this client? A. Giving the instructions without reading them B. Checking the instructions for grammar and spelling C. Ascertaining the client's level of education D. Asking if the client wants the material

B Misspelled words, misplaced punctuation, or incorrect grammar can change the intended meaning of the material and lead to confusion and harm to the client.

A nurse makes an entry in a client's chart that includes documentation about the routine care, assessment findings, and client problems. This documentation is arranged in a chronological order, from the time the nurse started the shift until the nurse entered the documentation in the client's record. What type of charting is the nurse using to document client care? A. Source-oriented recording B. Narrative charting C. Plan of care D. Problem-oriented recording

B Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used.

The nurse enters a client's room and finds that the phone is lying on the client's lap, tissues are wadded up on the bed, and the client's eyes are red and watery. What is the best response by the nurse? A. "Has your doctor been in to talk to you yet?" B. "You look upset, is there anything you'd like to talk about?" C. "Can I hand that phone up for you?" D. "Well, it's a beautiful day outside. Let's open the blinds."

B Nonverbal communication, or body language, often provides the nurse valuable information about what a person is feeling. The nurse can avoid barriers to effective communication by offering to listen to the client. The interpretation of such observations requires validation with the client.

A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating

B Reflecting directs the focus of the conversation back to the client so that he can further explore his own feelings.

The nurse is caring for a 6-year-old child who is about to undergo surgery. Which communication technique is most appropriate to alleviate the child's fear regarding surgery? A. Explaining the procedure to the child B. Using pictures and dolls to explain what will happen C. Talking to the parents in front of the child D. Soothing, nonverbal communication

B The 6-year-old will learn best from pictures and demonstrations on a doll rather than from explanations by the nurse.

The nurse educator is teaching a group of students about the importance of strong communication skills. The educator asks the group why strong communication skills are required in the nursing profession. Which student response is most accurate? A. "Strong communication skills are needed to perform certain highly technical tasks." B. "Strong communication skills are needed to deliver high quality client care." C. "Strong communication skills are required by the Nurse Practice Act." D. "Strong communication skills help to facilitate client discharge."

B The ability to communicate effectively plays a large role in the nurse's ability to deliver the highest quality of care to clients.

A 70- year-old client is being prepared for discharged after experiencing a fall. The nurse is planning to initiate teaching regarding safety in the home with the client, who is hard of hearing. What is the most appropriate nursing action when communicating with this client? A. Speaking slowly to the client B. Facing the client when speaking C. Speaking more loudly than usual D. Requesting hearing aids for the client

B The nurse prepares to change teaching habits and adapts to the client by facing the client during teaching. Most people with a hearing deficit learn to read lips. The nurse might also consider offering written material that the client can refer to at home.

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture.

B The nurse should be at the same eye level as the child to facilitate communication.

A client has specific cultural needs with regard to the plan of care. Where would the nurse locate information regarding cultural needs in the client's medical record? A. Progress notes B. Problem list C. Plan of care D. Database

B The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the client's physiologic, psychologic, social, cultural, spiritual, development, and environmental notes.

Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and the client. B. Encourage the client to communicate his thoughts and feelings. C. Give the nurse-client communication no time limits. D. Allow communication to occur spontaneously throughout the nurse-client relationship.

B Therapeutic communication facilitates a helping relationship that maximizes the client's ability to express his thoughts and feeling openly.

The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, the new area of skin breakdown appears to be caused by the tape used to secure the dressing. This would be an example of which phase of the nursing process? A. Implementation B. Evaluation C. Assessment D. Diagnosis

C Assessment is the collection, organization, validation, and documentation of data. Assessment is continued throughout the nursing process, as in this case.

According to research design, once the research problem is defined, what is the next step in the process? A. Define variables B. Formulate a hypothesis C. Review the literature D. Select a design

C Before progressing with the research design, the researcher determines what is known and not known about the problem. A thorough review of the literature provides the foundation on which to build new knowledge.

A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. What would the case manager identify for this client by using a critical pathway? A. An error in judgement on the case manager's part B. An unattainable goal C. A variance D. An incorrectly written care plan

C Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is called a variance. Variances are deviations from what is planned in the critical pathway-unexpected occurrences that affect the planned care or the client's response to care.

A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of risk for falls related to unsteady gait, secondary to neurologic dysfunction, has been formulated. A goal for this client is to not sustain any injuries for the next month. The client, however, has fallen several times. What is the most appropriate action for the nurse to take at this time? A. Modify the whole nursing plan. B. Review the data and make sure that the diagnosis is relevant. C. Investigate whether the best nursing interventions were selected. D. Discard the nursing plan and start over from the assessment phase.

C Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with foal achievement. The nurse needs to check to see if the interventions were appropriate for the client. If the interventions selected did not help the client achieve the goal, then rearranging or implementing new ones may be necessary.

The nurse is doing teaching regarding medication administration for a client who is being discharged. Which instructions should be rewritten for this client? A. Lasix, 20mg by mouth 8 AM and 2 PM B. Lasix, 20 mg by mouth twice a day C. Lasix, 20 mg po bid D. Lasix, 20 mg twice daily

C If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layman's terms, and use of medical abbreviations should be avoided.

The new nurse is interested in learning more about nursing research. The nurse preceptor would describe a literature review as all except: A. A means for the student nurse to identify past research finding on the research topic B. A way to look for clinical evidence from research sources C. A non-essential part of the research process D. Is part of the evidence retrieval process of the research process

C Looking for clinical evidence from research sources usually includes a review of the pertinent literature related to the subject. It provides a means to identify past research finding on the research topic, is a part of the evidence retrieval process of the research, and is an essential part of the research process

A nurse is caring for a confused 72-year-old client with Alzheimer disease. What is the best communication strategy for this client? A. Written direction for bathing B. Flat facial expression C. Gentle touch when providing care D. Speaking very loudly

C Nonverbal, gentle touch is an important tool for use with the older, confused client.

The nurse is preparing to turn client care over to the next shift. The client asks the nurse to wait in the room instead of leaving, because the client is along until the next nurse arrives. What is the best response by the nurse? A. "I'll find your spouse to sit with you." B. "You will be fine for half an hour." C. "I need to tell the new nurse how you are progressing with care." D. "You do not need a nurse in the room all the time."

C Nurses give reports to the next shift in order to make sure that client care is progressing in a positive manner, and that changes in client response over the last shift are identified for the next shift.

The nurse preceptor tells the nursing student that participation in nursing research will most likely help the student: A. Develop a better attitude about work B. Improve the development of skills C. Improve daily practice D. Improve communication with clients

C Nursing research aims to help nurses improve daily practice by increasing nursing knowledge.

Regarding research and nursing care, the ANA expects that all nurse will: A. Create research questions B. Improve assessment skills C. Integrate research findings into care D. Report findings to clients

C The ANA established research standards with the goal that nurses will integrate findings into improved care for the client.

An infant has been admitted to the pediatric unit. The parents are quite worried and upset; the grandmother is also present. The nurse should obtain data from which source? A. Grandmother, since the parents are upset B. Admitting physician C. Parents D. Medical record from the child's birth

C The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. Even though the parents are upset, they would be able to provide the nurse with the most accurate, current information regarding the baby.

The new nurse is learning to develop assertive communicating with clients and other health care professionals. Which aspect regarding assertive communication is the most important when using this style of communication? A. Being passive until more experience is gained B. Being careful to place blame appropriately C. Being aware of one's body language D. Making careful judgments

C The new nurse is aware that body language is an important factor when communicating and would include an open, relaxed stance, and appropriate tone of voice. The assertive nurse is nonjudgemental.

A client comes into the emergency department with a non-life-threatening wound to the hand that will require stitches. The department is quite busy with several clients, their families, and other people in the waiting room. Which would be the best method for the nurse to choose to conduct the interview? A. Have the client wait until the department quiets down, since the would is not too serious. B. Make sure the client's back is to the rest of the room so the conversation will not be heard by passerby. C. Draw curtains around the client and nurse to provide as much privacy as possible. D. Tell the client to wait in the waiting room and fill out the paperwork.

C The nurse is preparing to conduct an assessment of the client but also implements the best method or setting for the assessment.

When learning how to implement the nursing process into a plan of care for a client, the instructor asks the student nurse what the purpose of the nursing process is. Which comment made by the student nurse demonstrates her understanding of the purpose of the nursing process? A. "To deliver care to a client in an organized way." B. "To make sure that standardized care is available to clients." C. "To identify client needs and deliver care to meet those needs." D. "To implement a plan that is close to the medical model."

C The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.

The nurse is assessing a postoperative client for pain and notes that the client is holding the surgical site and exhibiting facial grimaces. The client denies pain when asked. What part of the communication process needs would the nurse further clarify? A. Sender B. Feedback C. Message D. Receiver

C When the spoken message and the nonverbal message are incongruent, the nurse needs more information in order to choose an intervention.

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statement should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used to it." B. "Why are you worried about going home?" C. " Your daily routines will be different when you get home." D. "Tell me about your support system you'll have after you leave the hospital." E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."

C, D, E Presenting reality is an effective communication technique that can help the client focus on what will really happen after the changes the surgery has made. Asking open-ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the client to express feelings through dialogue and offer additional information. Offering self is an effective communication technique that can convey understanding and share another's experience with the client. However, the nurse should return the focus to the client as soon as she communicates the relevant point.

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that so not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) A. Writing a prescription for morphine sulfate as needed for pain. B. Inserting a nasogastric (NG) tube to relieve gastric distention. C. Showing a client how to use progressive muscle relaxation. D. Performing a daily bath after the evening meal. E. Repositioning a client every 2 hr to reduce pressure ulcer risk.

C, D, E Showing a client how to use progressive muscle relaxation is an appropriate nurse-initiated intervention for stress relief. Unless it is a contraindication for a specific client, the nurse can use this technique with clients without a provider's prescription. Performing a bath is a routine nursing care procedure. Unless it is a contraindication for a specific client, the nurse can determine when bathing is optimal for a client without a provider's prescription. Repositioning a client every 2 hr is an appropriate nurse-initiated intervention for clients. Unless it is a contraindication for a specific client, the nurse can use this strategy without a provider's prescription.

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which is the most appropriate type of diagnosis for this client? A. An actual diagnosis B. A syndrome diagnosis C. A risk nursing diagnosis D. A wellness diagnosis

D A wellness diagnosis describes the human response to levels of wellness in an individual. This client is seeking information about behavior changes and improvement for help in making choices and changes to enhance his life.

A client is being transferred to a rehabilitation center for more long-term care after a long period of hospitalization. As the client is preparing to be discharged, the client asks the nurse if he can take his chart, since it's his record. What is the best response by the nurse? A. "There's a new law that protects your records, so you won't be able to have access to them." B. "We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details." C. "You'll have to ask your doctor for permission to do that." D. "Actually, the original record is the property of the hospital, but you are welcome to copies of your records."

D Although the client's record is protected legally as private, access to the record is restricted to health professionals involved in the client's care. The institution or agency is the rightful owner of the client's record, but the client has the right to access all information contained within his own record and to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The Health Insurance Portability and Accountability Act is a law enacted to protect health information and maintain confidentiality of clients records.

Assertive communication is an appropriate approach for nurse to use in the clinical area. It decreases the risk for miscommunication with colleagues, clients, and their families. Which statement is an example of this type of communication when the nurse addressed the physician? A. "You need to check the laboratory results of the client in room 423." B. "You should visit with the client's family about the upcoming procedure." C. "We need to be more aware of the situation between the client and the client's family." D. "I am concerned that the client does not have adequate pain management."

D An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. "You" statements place blame and put the listener in a defensive position. "I" statements encourage discussion.

The nurse is caring for a client who is recovering from a myocardial infarction. The nurse has assumed the role of an assertive communicator to effectively deal with the client's family members. How will this type of communication impact this client's care? A. It will increase the likelihood of angry encounters B. It will reduce the need for outside mediators C. It will increase feeling of victimization D. It will reduce stress felt by the client and family

D Assertive communication improves communication and reduces stress by de-escalating conflict, improving outcomes, and reducing the likelihood of angry encounters.

A nurse is caring for a client who experiences a cardiac arrest. The client's spouse is in the room when the code team arrives. Which statement by the nurse is most appropriate? A. "Your spouse's physician will be here shortly and explain all the medication and treatment that your spouse is receiving right now." B. "Is there someone you would like to call? I'm sure this is a scary situation and you may feel more comfortable if someone were with you during this time." C. "I know you're worried about your loved one. I'm sure this is a difficult situation for you. Do you have any questions right now?" D. "Your spouse's heart stopped. All these people are here to help get it started."

D Clarity and brevity provide a message that is simple and clear.

A hospital does not receive reimbursement for a particular client who received treatment while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which documentation issue may have caused the lack of reimbursement? A. The client was charged for an ECG B. The client's record contained an incorrect DRG C. A code cart opened and the client was charged for medication the client did not use. D. The physician make a diagnostic mistake.

D Documentation helps a facility receive reimbursement from the federal government. The client's clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Codable diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses.

A new client has been admitted to the unit during the night shift. The admitting nurse identifies the client by name, room, and bed number. What other piece of information would the nurse include? A. Client evaluation B. Spouse's name C. Nursing history data D. Reason for admission

D Following the client's name and location on the unit, the nurse would next give the reason for admission.

A nurse works in a hospital that utilizes a charting by exception documentation system. When providing care and performing assessments, the nurse may not address all the sections on a client's flow sheet, especially if the client did not require the particular care mentioned in these sections. Which course of action should the nurse use to indicate that these areas were addressed although no care was needed? A. Leave them blank, but then add an extensive explanation in the progress notes section of the chart. B. Leave them blank. C. Make sure this information gets passed along in the shift report. D. Write N/A on the flow sheet in the areas that are not applicable to that client.

D Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank.

To impact cost containment in the delivery of health care, the nurse suggests the need for future research studies. The nurse would look to studies that would: A. Evaluate the emergency response to disaster B. Improve client safety C. Examine end-of-life care D. Promote healthy lifestyles

D Nurses can help with health cost containment by concentrating on wellness, healthy lifestyles, and disease prevention. It is more cost effective to prevent illness than to treat illness.

The nurse is caring for a client on the medical-surgical unit. The client asks who has access to their medical record. Which response by the nurse is most appropriate? A. Nurses employed at the hospital can access your medical record. B. Physicians employed at the hospital can access your medical record. C. Your family members can access your medical record. D. Nursing student caring for you can access your medical record.

D The American Nurses Association code of ethics states that "the nurse has a duty to maintain confidentiality of all patient information." The client's record is also protected legally as a private record of the client's care. Access to the client's record is restricted to health care professionals involved in giving care to the client. For purposes of education and research, most agencies allow student and graduate health care professionals access to client records.

A graduate nurse is instructed to use the mnemonic PICOT to define and formulate a clinical question that will contribute to Evidenced Bases Practice. The nurse understands that this question will include all except: A. Outcomes B. Comparison on interventions C. Population of clients D. Implementation of hypothesis

D The nurse utilizing the PICOT format to formulate a clinical question understands that the mnemonic includes: Population of clients, issue of interest, Comparison of interventions, Outcomes and Time frame.

The nurse is preparing to document a client's care in the medical record. Which order uses abbreviations that are appropriate? A. .2 mg morphine sulfate every 4 hours B. Ambulate QOD C. 200 mg ibuprofen bid D. 10 units Regular insulin ac

D The order for 10 units Regular insulin ac is correctly written appropriate abbreviation.

In order to overcome some of the barriers to evidence-base practice (EBP), the nurse manager plans to: A. Have the nurses petition the administration for support B. Ask the nurses on the unit to go back to school C. Buy computers for the nursing staff D. Ask the nurses to read articles and report to the unit

D There is a wealth of knowledge and research in nursing journals. The manager could ask each nurse to read an article and then report a summary during staff meetings.

During the change-of-shift report, the nurse reports that the client is having "respiratory difficulty." What should the nurse add to this report? A. "I called the doctor, but he didn't do anything." B. "And I put her on 3 liters of oxygen." C. "But she seems okay." D. "Her respiratory rate is up to 28 breaths/min; oral temperature is 100 degrees; heart rate is 96 beats/minute; o2 saturation of 90%."

D When giving the change-of-shift report, the nurse should use a guide, begin by giving background information of the client, be specific, describe abnormal findings and provide supporting evidence, and stress any abnormal findings.

The nursing is caring for several clients who are residents at a long-term care facility. How often must the nurse complete a nursing care summary for a client who is receiving skilled care? A. Once every two weeks B. Summaries are not required for skilled care C. Once a month D. Once a week

D Nurses need to familiarize themselves with regulations influencing the kind and frequency of documentation required in long-term care facilities. Usually the nurse completes a nursing care summary at least once a week for clients requiring skilled care and every 2 weeks for clients who require intermediate care.