Nursing 112 Exam #3 Ch. 16, 26, 32, 34, 36, 37

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"is your child breathing at this time?"

A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to:

experimentation with drugs and inhalants.

What teaching will the community health nurse include for parents of toddlers?

household cleaners must be kept out of reach

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

incident report

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

problem-oriented method

incident reports

used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client?

*Check agency policy for the application of restraints and secure a physician's order. *Remove the restraint at least every 2 hours or according to agency policy and client need. *Pad bony prominences.

when is it not necessary for a nurse to obtain a signed authorization from a client?

*Reporting the incidence of an infectious disease to Centers for Disease Control and Prevention *Releasing a medical record to the court when a nurse is being sued for negligence *Facilitating organ donation of a deceased client *Providing statistics related to the use of a dangerous piece of equipment

The nurse in making an entry on the client's chart: "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time?

0000

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion?

Headache Vomiting Drowsiness

What dual purpose does an audit serve?

Quality assurance and reimbursement

flow sheet

a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics.

charting by exception (CBE)

a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

assessment of vital signs and respiratory status

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?

client's record and occurence report

problem-oriented recording

emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

SOAP charting

everyone involved in a client's care makes entries in the same location in the chart. it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

inform the provider that a written order is needed

A nursing student asks why completing an acuity report is important. What is the best response by the nurse?

it helps determine staffing requirements

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution.

The client record serves as a _____________ _______________ of the client's health status and care received.

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