Foundations of Nursing Chapters 26 & 27

"I will use extension cords at all times."

A registered nurse (RN) is teaching a patient about preventive measures for electrical shocks. Which statement by the patient indicates the need for further teaching?

"The subjective and objective data are included in problem, intervention, evaluation (PIE) charting."

A registered nurse is teaching a group of student nurses about the nursing process in a hospital. Which statement made by a student nurse indicates the need for additional teaching?

Variance

A critical pathway in an orthopedic unit indicates that a patient should be afebrile, normotensive, and eupneic after knee replacement surgery. The nurse performs a postoperative examination of a patient's status after left knee replacement surgery and finds that the patient is experiencing a low-grade temperature. What is this finding called?

Enter only objective and factual information about the patient.

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "The patient is difficult to care for and refuses suggestions for improving appetite." Which directions does the manager give to the staff nurse who entered the note?

The new nurse gives a newly ordered medication before entering the order in the patient's medical record.

A new graduate nurse is providing a telephone report to a patient's healthcare provider and accepting telephone orders from the provider. Which actions require the new nurse's preceptor to intervene?

Do not share passwords with anyone. Do not leave the patient's medical record open unattended on a computer screen. Do not log in with someone else's user access.

A nurse manager is educating the nursing staff on the importance of security with the implementation of the electronic health record (EHR) on the unit. What points does the manager emphasize?

Blood pressure Thick, yellow phlegm Presence of wheezes and rhonchi

A patient complains of not feeling well and is coughing frequently with copious phlegm. Coughing is worse at night. During the initial assessment, the nurse finds that the patient coughs violently for 40 to 45 seconds with thick, yellow phlegm. The blood pressure is 150/90 mm Hg, pulse rate is 92 beats/minute, and respiratory rate is 22 breaths/minute. Wheezing and rhonchi are present in both lung bases. The patient expresses having chest pain when coughing and the pain radiates to the arm. Which data should the nurse document as objective data?

Raise the bed to the level of the stretcher. Cross the patient's arms on chest while transferring. Involve multiple caregivers for safe transfer.

A patient is being transferred from bed to stretcher. Which precautions should the nurse take to ensure patient safety during transfer?

The contact information of the healthcare provider The step-by-step instructions for self-administration of insulin The signs and symptoms that have to be reported to the healthcare provider

A patient is diagnosed with acute renal failure due to diabetes. Following treatment, the patient recovers. The patient is being discharged to home on insulin. The nurse is preparing a discharge summary for the patient. What information should the nurse provide in the discharge summary?

Pressure ulcers

A patient is undergoing treatment in a long-term health care facility. Which type of immobility complication is likely to develop in the immobilized patient?

Eliminate the risk of falls. Consult with a physical therapist. Recommend an assessment of the eyes.

A patient sustained a cerebrovascular accident. The patient reports associated weakness on the left side of the body. On further assessment, the nurse learns that the patient has a visual disturbance and uncoordinated gait. How should the nurse ensure the patient's safety?

Calcium imbalance Gastrointestinal disturbances Alteration in the metabolism of protein

A patient sustained a severe injury in a motor vehicle accident. The patient is unable to perform any movement. Which metabolic changes would be found in the patient due to immobility?

This report helps in identifying loopholes in the operation of the healthcare system. This report helps in providing good, quality healthcare. This report helps to identify the need to change a procedure or policy.

A patient sustains an injury from a fall while on a hospital unit. The nurse makes an incident report. What is the purpose of the incident report?

Reminding the patient to scan the environment while walking

A patient was diagnosed with left-sided neglect after suffering a cerebrovascular accident. Which nursing intervention would be most effective to ensure the patient's safety?

Stage III pressure ulcers acquired after admission to a health care facility

According to the National Quality Forum, which event is considered a care management event?

Record pertinent health and drug information. Record medications that are given and any drug reaction. Document discontinued medication.

According to the court of law, "a care not documented is care not provided." What are the proper ways of documenting a patient's information?

Written reports Oral communication

Communication among the members of a healthcare team is essential to providing quality care to patients. Which are the modes for exchanging information among the members of the healthcare team?

1

How many nurses would be required to place a patient in the semi-prone position?

Having the baby sleep on his or her back

In a pediatric ward, one of the newborns died of sudden infant death syndrome (SIDS). Which nursing measure lowers the risk of death due to SIDS?

Subjective Assessment

The nurse assesses a patient postoperatively and charts the findings in a SOAP note. What elements are integral to the SOAP note?

The documentation justifies reimbursement. The documentation provides information regarding quality of work. The documentation provides the health care team with detailed knowledge for coordination of care.

The nurse caring for a patient in a home care setting needs detailed documentation. What are the purposes of the documentation?

Leave a night light on in the bathroom Provide scheduled toileting during the night shift Keep the pathway from the bed to the bathroom clear.

The nurse found an elderly female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient?

Placing trochanter rolls parallel to the lateral surface of the thighs

The nurse is assisting a patient in the supported supine position. Which nursing action should the nurse implement to reduce the rotation of the hip?

Denis Browne splint

The nurse is caring for a child with clubfoot. Which should the nurse advise the caregiver to apply on the child?

Temperature 100.2° F Respiratory rate 28 breaths/minute Heart rate 98 beats/minute

The nurse is caring for a patient who has undergone abdominal surgery. The patient informs the nurse of discomfort in the abdomen and is unable to turn to the left side. The nurse finds that the patient has a temperature of 100.2° F, a respiratory rate of 28 breaths/minute, and a heart rate of 98 beats/minute. Which data should the nurse chart under the O in SOAP charting?

Nursing diagnosis of the patient Important information about family members Recent changes in objective measurements

The nurse is caring for a patient who is diagnosed with renal failure due to diabetes. The nurse has to pass the patient care to another nurse during change of shift. Which information should the nurse include in the hand-off report?

Thrombus formation Orthostatic hypotension Increased circulating fluid volume

The nurse is caring for a patient who is immobile. Which cardiovascular changes does the nurse expect to observe in the patient?

Room number Demographic details Date of birth

The nurse is discussing a case history in a clinical conference. Which patient information should the nurse exclude from mentioning to maintain confidentiality of the patient?

Charting by exception

The nurse is given a form with preset standard findings for recording a progress note. The nurse reports the findings in the following way: "Physical Exam: All systems within normal except left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain in the left foot." What kind of documentation and informatics is this?

It documents deviations. It uses a shorthand method. It documents significant findings.

The nurse is learning how to chart. On what does charting by exception focus?

Saving time Minimizing error Effective continuity of patient care

The nurse understands that documentation is an important part of nursing care. What are the advantages of effective documentation?

Record all facts. Record all written entries legibly and in black ink. Begin each entry with date and time and end with signature and title.

The nurse understands that patient records are legal documents and should be accurate. What precautions should the nurse take when documenting?

Bend at the knees. Maintain an erect trunk and bent knees. Get assistance when moving patients. Keep the weight to be lifted as close to the body as possible.

The nurse understands the increased risk of musculoskeletal injuries due to activities such as lifting objects, pushing beds, and bathing and feeding patients. Which measures should the nurse adopt to prevent injury?

Isometric exercises increase the muscle mass of the body. Muscle tension increases, but there is no muscle shortening.

The patient is advised to perform pelvic floor exercises. The nurse explains to the patient that pelvic floor exercise is a type of isometric contraction. Which statements are true about isometric contractions?

The patient had 2 cups of soup, which was tolerated well.

The primary healthcare provider orders a clear liquids diet for a patient with gastritis. On the first day, the patient consumes soup and tolerates it well. How does the nurse document this finding?

"I will make regular safety checks of equipment."

The registered nurse (RN) is teaching a nursing student about safety for equipment-related accidents. Which statement by the nursing student indicates the need for further learning?

"I should stay with the patient." "I should position the patient safely." "I should note the time of the seizure."

The registered nurse (RN) is teaching a patient's family members tips for protecting the patient during a seizure attack. Which statements made by a family member indicates the need for further teaching?

Student nurse 4

The registered staff nurse is evaluating the documentation of four student nurses. Which student nurse's documentation does the registered nurse correct, according to the legal guidelines for recording?

Install deadbolts on exterior doors above the child's reach.

The registered staff nurse provides various instructions to the caregiver of an infant before discharge from the hospital. Which instruction promotes safety for the infant?

The legs are bent outward.

When reviewing the medical record of a 3-year-old child, the nurse finds that the child has genu varum. What finding should the nurse expect in the child?

Admission sheet

When the nurse needs to notify a patient's guardian about the patient's health status, where does the nurse access the information to contact the guardian?

Patients who have angina Patients who are homeless Patients who have taken a drug overdose

Which patients are at high risk of hypothermia?

"You should touch one side of the body frequently with the other hand."

Which suggestion would be appropriate to prevent unilateral neglect in a patient with hemiparesis?

Increase intake of vitamin D. Increase intake of calcium. Increase intake of phosphorus.

While assessing a patient with rickets, the nurse finds that the patient has bowlegs. Which appropriate interventions should the nurse suggest to the patient's parents?

Respiratory rate 28 breaths/minute

While assessing a postoperative patient, the nurse observes that the patient is unable to sleep in the lateral position. Which assessment finding indicates an increased risk of developing complications due to immobility?

Difficulty focusing during conversations Difficulty understanding medication instructions

While caring for a patient with left-sided weakness, the nurse suspects anxiety related to fear of falling. Which assessment findings would further confirm the nurse's suspicion?

Supine position

While caring for a postoperative patient, the nurse spreads trochanter rolls on the bed before positioning the patient. In which position is the nurse preparing to place the patient?

The patient's name, age, and admitting diagnosis Allergies to food and medications That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of acetaminophen

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which pieces of information do you include in the report?

You need to use words the patients can understand when writing the directions.

You are helping to design a new teaching sheet that will go home with patients who are discharged home from your unit. Which option do you need to remember when designing the teaching sheet?

HIPAA provides you with greater control over your personal healthcare information.

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which option is the best response?