Module 2

Which describes the anatomical relationship of the wrist to the elbow? The elbow is proximal to the wrist. The elbow is distal to the wrist. The elbow is superficial to the wrist. The elbow is lateral to the wrist.

The elbow is proximal to the wrist.

How can the nurse make nurses' notes brief? Select all that apply Use abbreviations Replace words with their synonyms Cut down on the amount of information use symbols and acronyms Replace detailed sentences with matter of fact statements Remove all the medical terms used

Use abbreviations Replace words with their synonyms use symbols and acronyms Replace detailed sentences with matter of fact statements

Which characteristic of a well-written goal statement is not met in the goal statement: Patient will understand how to use a sliding scale to administer insulin coverage to manage blood sugar levels by discharge to home? Uses a measurable verb Is realistic for the patient's problem Includes a time frame for patient re-evaluation Is specific to the patient or the patient's problem

Uses a measurable verb

multi-state licensure

agreement with another state that says if you're licensed in one state your licensed in another

Define Sentinel Event

any unexpected occurrence involving death, serious physical/psychological injury or the risk.

activities of daily living (ADLs)

basic self-care tasks such as eating, bathing, toileting, walking, and dressing

While orienting to a new facility, which statement by the nurse to the nurse preceptor indicates accurate understanding of a clinical pathway? "It refers to a system of care where patient care is coordinated by one nurse or person. "This process refers to analyzing a variance to determine why an outcome was not achieved." "It is a multidisciplinary plan of care that incorporates evidence-based practice to provide optimal patient outcomes." "Clinical pathways describe a health care system that attempts to decrease costs by reducing unnecessary or overlapping Services,

"It is a multidisciplinary plan of care that incorporates evidence-based practice to provide optimal patient outcomes."

When reviewing charting documented using the SOAPE model, which entry under the "S" portion of the model requires correction? O "Nurse to continue to measure wound once a week." O "Dressing changed with sterile 4 x4 wrapped with gauze." "Patient reports pain level of 8 out of 10 during dressing changes." O "Use sterile normal saline to loosen dressings before removal.

"Patient reports pain level of 8 out of 10 during dressing changes."

While orienting to a new facility, which statement by the nurse to the nurse preceptor indicates accurate understanding of a clinical pathway? O "It refers to a system of care where patient care is coordinated by one nurse or person." O This process refers to analyzing a variance to determine why an outcome was not achieved. O "it is a multidisciplinary plan of care that incorporates evidence-based practice to provide optimal patient outcomes. O "Clinical pathways describe a health care system that attempts to decrease costs by reducing unnecessary or overlapping services

"it is a multidisciplinary plan of care that incorporates evidence-based practice to provide optimal patient outcomes.

Clinical (Critical) Pathways

- A systematic approach that provides a framework to target the coordination of medical and nursing interventions - Allows staff from all disciplines to develop integrated care plans for a projected length of stay for a specific case type

The Joint Commission

- The accreditation agency specifying guidelines for charting - Documentation of client care, time it was provided &signature of the person who is documenting, provesthat the Person who signed it, did all the work noted& interventions were carried out to meet the client'sneeds. - Nursing documentation must be based on assessment - Information recorded in the chart should be clear, concise, complete, and accurate

Eight categories of disciplinary actions taken against nurses

1. Fraud and deceit 2. Criminal Activity 3. Negligence 4. Violation of NPA 5. Discipline by another jurisdiction 6. Incompetence 7. Unethical conduct 8. Alcohol and/or other drug abuse

Two kinds of biological attacks

1. Overt (announced) 2. Covert (unannounced)

When should possibility of a bioterrorism-related outbreak be considered?

1. Rapidly increasing incidence of a disease is normally healthy population 2. Unusual increase in number of people seeking care (fever, respiratory, gastrointestinal) 3. Epidemic disease 4. Lower incidence of people getting sick indoors compared to outdoors 5. Clusters of people arriving6. Large amount of cases, quickly fatal

How to evaluate use of SRD

1. make sure used correctly 2. Asses body party every 30 minutes, release every 2 hours.

What materials are include in each type of fire 1. Type A 2. Type B 3. Type C

1. paper, wood, cloth 2. flammable liquids, grease and anesthetics 3. Electrical

SBAR

A method of communication among health care workers and a part of documentation; considered a safety measure in preventing errors from poor communication during hand-off or hand-over interactions

Diagnosis-related groups

A system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount

Kardex, or Rand

A system used to consolidate patient orders and care needs in a centralized, concise way

DARE

Acronym used for the focused charting format

interstate endorsement

Agreement among states that licensed nurses do not have to repeat NCLEX-PN exam if they meet criteria for working in the state.

Electronic Health Record (EHR)

An electronic patient record designed for health information exchange between facilities

The nurse is teaching nursing students about the activities involved in determining a patient problem. Which action by the nursing student indicates the need for additional teaching? Checking the patient for activity intolerance and functional ability Asking whether the patient has urinary stress, incontinence, and related signs Checking the patient's temperature, blood pressure, respiration, and heart rate Informing the patient that he or she has diabetes mellitus as indicated by elevated glucose levels

Asking whether the patient has urinary stress, incontinence, and related signs

A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurse's focus? Planning Assessment Implementation Patient teaching

Assessment Rational: DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E).

Which interventions can a nurse prescribe or initiate legally? Select all that apply. Codeine Wound care Back massage clear liquid diet Relaxation exercises Turning every 2 hours

Back massage Relaxation exercises Turning every 2 hours

An infant is born in an unstable condition into a Roman Catholic Family. The nurse understands that the child may die without being seen by a priest. Which intervention would be included in the plan of care? Baptism Communion Last rites Prayer

Baptism

Which components are necessary for a well-written patient outcome statement or goal? Select all that apply Being specific to the patient Being realistic for the patient Including a time frame for completion Giving indications of a worsening of the problem Listing all of the interventions required for meeting the goal

Being specific to the patient Being realistic for the patient Including a time frame for completion

Which components are necessary for a well-written patient outcome statement or goal? Select all that apply. Being specific to the patient Being realistic for the patient Including a time frame for completion Giving indications of a worsening of the problem Listing all of the interventions required for meeting the goal

Being specific to the patient Being realistic for the patient Including a time frame for completion

What are the three buffer systems of the body? (Select all that apply.) Bicarbonate/carbonic acid system Respiratory system Renal system GI system Integumentary system

Bicarbonate/carbonic acid system Respiratory system Renal system Rational: The bicarbonate/carbonic acid system, the respiratory system, and the renal system are the buffer systems of the body.

The opposite term for posterior in humans is superior. anterior. ventral. both B and C.

Both B and C

The nurse collects data from a patient admitted to a long-term care facility. Which actions are important aspects of planning care for this patient? Select all that apply. Set goals to eliminate identified problems. Evaluate the patient's response to the intervention, Obtain information from other health care professionals, Document the patient's response to the intervention. Collaborate with the patient before choosing the intervention

Collaborate with the patient before choosing the intervention Set goals to eliminate identified problems.

The nurse administers pain medication to a patient who rates his postoperative pain as a 9 on a scale of 1 to 10. Which nursing intervention evaluates the effectiveness of the intervention? Select all that apply. Document the patient's response. Add collected data to the nursing care plan. Compare pre- and post-pain assessment data. Determine whether the expected outcome was achieved. Determine whether the intervention was effective and take further action, if needed.

Compare pre- and post-pain assessment data. Determine whether the expected outcome was achieved. Determine whether the intervention was effective and take further action, if needed.

A nurse on the evening shift reviews a chart and finds that the patient did not receive a morning dose of insulin as prescribed. After notifying the charge nurse, which nursing action is priority? Administer the medication and check the glucose level. Complete an incident report according to hospital policy Telephone the morning nurse for a detailed explanation of the event Monitor the patient and notify the primary health care provider if a change occurs in the patient's condition

Complete an incident report according to hospital policy

A nurse has completed the initial data collection from a patient with a chronic mental disorder. How does the nurse organize and cluster data? Obtain diagnostic tests. Perform a physical assessment. Consider the assessment database. Determine the desired outcomes

Consider the assessment database.

When a nurse reflects on care that was given and determines what was effective, in addition to analyzing and adjusting given care, which process is involved? Critical thinking The nursing notes The patient problem statement The nursing care plan

Critical thinking

Which source of data is included in resources the nurse may use as secondary sources of data? Select all that apply Patient Dietitians Medical records Previous nursing progress notes Physical therapists Diagnostic procedures

Dietitians Medical records Previous nursing progress notes Physical therapists Diagnostic procedures

While reviewing the patient's nursing care plan to prepare for the shift, which statement would the nurse identify as a nurse-prescribed intervention? Administer 10 units of insulin glargine each day at bedtime. Patient correctly identified signs and symptoms of low blood sugar. Patient will identify foods to include in a healthy eating plan to manage diabetes by discharge. Educate patient about maintaining a healthy weight and regular physical activity to manage diabetes before discharge.

Educate patient about maintaining a healthy weight and regular physical activity to manage diabetes before discharge.

A nursing student is completing clinical forms. If found on the medical records, which diagnosis would the student research to prepare care for this patient? Emphysema Knowledge deficit Alteration in nutrition Ineffective airway exchange

Emphysema Rationale: Emphysema is a medical diagnosis, which is the identification of a disease or condition based on evaluation of physical signs, symptoms, patient interview, laboratory test results, findings of diagnostic procedures, review of medical records, and patient history.

During which phase of the nursing process would the nurse anticipate possibly making modifications to the nursing care plan? Planning Evaluation Assessment Goal Identification .

Evaluation Rational: Changes are often made in the evaluation phase if the identified goals were not met. The nurse generally does not anticipate making changes during the planning, assessment, or goal identification phases.

Which phrase best describes the outcomes identification phase of the nursing process? Select all that apply The information received from the patient during a physical assessment A set of expected obligations the patient is required to meet at discharge Expected outcomes for diagnoses developed by the patient and the nurse Required criteria that a primary health care provider develops for a nurse to achieve before shift change

Expected outcomes for diagnoses developed by the patient and the nurse

Malpractice

Failure by a health professional to meet accepted standards

What is a common injury that occurs at health care facilities?

Falls

Which document should the nurse manager check to verify a patient's progress? O Consultation sheet O Admission form O Flow sheet O Ancillary staff sheet

Flow sheet Rationale: The flow sheet tracks routine assessments, treatments, and frequently given care; hence, the nurse manager has to check the flow sheet to understand the patient's progress. The consultation sheet is a record of an additional primary health care provider called in to consult by the attending primary health care provider. The admission form gives information on patient identification, conditions for admission, and consent for general medicine and care. The ancillary staff sheet is a record of treatments provided by physical therapist, occupational therapists, and respiratory therapists.

Which function does the patient goal statement serve on a patient's care plan? Select all that apply. Establishes priorities for nursing care Guides selection of nursing interventions Identifies the patient's response to a health problem Reduces or eliminates the problem's causative factors Establishes measuring standards to evaluate nursing intervention effectiveness

Guides selection of nursing interventions Establishes measuring standards to evaluate nursing intervention effectiveness

Which function does the patient goal statement serve on a patient's care plan? Select all that apply. Establishes priorities for nursing care Guides selection of nursing interventions Identifies the patient's response to a health problem Reduces or eliminates the problem's causative factors Establishes measuring standards to evaluate nursing intervention effectiveness

Guides selection of nursing interventions Establishes measuring standards to evaluate nursing intervention effectiveness

While gathering data, the nurse discovers that the patient is suffering from a life threatening disorder. Of the care priorities below, which category is this patient's care? Low-priority High-priority Ultimate-priority Medium-priority

High-priority

A clinical pathway is a tool for which type of health care? Low-risk, low-volume, low-cost cases High-risk, low-volume, low-cost cases High-risk, high-volume, high-cost cases High- or low-risk, high- or low-volume, high- or low-cost cases

High-risk, high-volume, high-cost cases

The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem that may increase because of the use of SRDs? (Select all that apply.) Immobility Lethargy Risk for impaired circulation Risk for skin impairment Incontinence

Immobility Risk for impaired circulation Risk for skin impairment Incontinence

The nurse is teaching nursing students about the activities involved in determining a patient problem. Which action by the nursing student indicates the need for additional teaching? Checking the patient for activity intolerance and functional ability Asking whether the patient has urinary stress, incontinence, and related signs Checking the patient's temperature, blood pressure, respiration, and heart rate Informing the patient that he or she has diabetes mellitus as indicated by elevated glucose levels

Informing the patient that he or she has diabetes mellitus as indicated by elevated glucose levels

When caring for a patient with pneumonia, which information would the nurse refrain from documenting in the patient's chart? Is not listening to information Shortness of breath on exertion Requires a walker for ambulation Refuses to use incentive spirometer

Is not listening to information

Which statement regarding information included in the Kardex system is true? O It includes only personal information. O It details only scheduled tests. O It covers the medication list without citing details of allergies. O It includes only surgery-related information.

It covers the medication list without citing details of allergies.

Which of these organs is an accessory organ of the digestive system? Stomach Liver Esophagus Small intestine

Liver

Problem-oriented medical record (POMR)

Method of recording data about the health status of a patient in a problem-solving system. Parts included are the database, problem list, initial plan, and progress notes

For a patient being evaluated for shortness of breath, which data would the nurse consider signs or objective data? Nurse notes breathing is very noisy. Patient reports feeling short of breath. Respiratory rate is 26 breaths/min. Patient is using accessory muscles to breathe. Patient is sitting in the high-Fowler's position to help ease breathing

Nurse notes breathing is very noisy. Respiratory rate is 26 breaths/min. Patient is using accessory muscles to breathe. Patient is sitting in the high-Fowler's position to help ease breathing

During which phase of the nursing process would the nurse anticipate possibly making modifications to the nursing care plan? O Planning O Evaluation O Assessment O Goal Identification

O Evaluation

What does the nurse use as a basis for documentation in focus charting? Problem list Nursing orders Patient problems Evaluation

Patient problems

complex nursing situation

Patient's clinical condition is not predictable. Medical and nursing orders are likely to involve continuous changes or complex modifications.

While the nurse is collecting data, the patient states, "I have had diarrhea for 3 days." The nurse notes this as which type of data? Tertiary Primary Secondary Secondhand

Primary

Which format of documentation involves the health care team using the same progress notes, flow sheets, and narrative notes? O Charting by exception (CBE) O Problem-oriented medical record (POMR) OProblem Intervention Evaluation O(PIE) charting O subjective Objective Assessment Plan Evaluation (SOAPE)

Problem-oriented medical record (POMR) Rationale: The POMR is organized according to the scientific problem-solving method. The problem list serves as the Index A team of primary health care provider, nurses, and therapists develop a care plan. All are required to document using the same progress notes, flow sheets, and narrative notes. CBE occurs when at the beginning of the shift, the nurse charts a complete assessment, observations, intravenous (V) site and rate, vital signs, and other pertinent data.

patient complains of breathlessness. Which nursing action is a part of the implementation phase of the nursing process? Assess the respiratory rate. Plan to provide oxygen therapy Prop up the patient in Fowler's position Assess whether the patient is feeling better

Prop up the patient in Fowler's position

After 2 hours, a nurse asks a patient to rate the abdominal pain. The patient replies, "The pain is just as bad as it was before I took the medication." Which intervention would be appropriate in response to the patient's statement? Monitor the patient for pain for the next 4 to 6 hours. Request a prescription for a stronger pain medication, such as morphine. Reassess the source of the pain to determine why pain relief has not occurred. Review side effects and contraindications for the pain medication the patient is receiving

Reassess the source of the pain to determine why pain relief has not occurred.

Which nursing action is inappropriate during the initial assessment phase? Obtaining patient history Referring to the assessment database Performing the physical assessment Gathering the results of diagnostic test

Referring to the assessment database

Omnibus Budget Reconciliation Act (OBRA) 1987

Regulated standards for resident assessment, individualized care plans, and qualifications for health care providers

Which action would the nurse take when documenting O clearly indicating goal-directed nursing care O Minimizing nursing notes to address priority nursing problems O Providing information about adverse events that occur throughout the day O Documenting subjective information provided by the patient, but not objective information

clearly indicating goal-directed nursing care

criminal action

deals with disputes between an individual and the society as a whole

clinical pathways

standardized multidisciplinary plans for a specific diagnosis or procedure that identify specific aspects of care to be performed during a designated length of stay

The majority of falls occur during _____ either to a beside commode or to a wheelchair

transfer

Whenever using a gait belt which side of patient do you walk on

weak side