NCLEX ?s Ch 15

Current client assessment

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Problem addressed

A newly hired nurse is participating in the orientation program for the healthcare facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as information to be recorded on the first line?

The time the specimen was ordered

A nurse caring for a client with bronchitis and phones the laboratory for the results of the client's sputum culture. Which of the following would be least appropriate to include when communicating with the laboratory?

Those directly involved with patient care.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which of the following would be entitled to access of the client's records?

Intervention carried out . P-Problems I- intervention E-Evaluation

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

Point of care documentation

A nurse is making a home visit to a client for the first time. The nurse is documenting assessment information on a laptop computer as each aspect of the assessment is completed. The nurse is using which of the following?

Use phrases in narratives

A nurse is preparing to document care provided to a client. Which of the following would be most appropriate for the nurse to do to ensure that the documentation is concise?

Interventions

A nurse is preparing to document information about a client using the FOCUS system. Which information would the nurse record in the action section?

Team leadership, communication, situation monitoring, mutual support

A nurse is working as part of a team that is presenting an in-service to the staff on the TeamSTEPPS program. Which skills would the nurse expect to be addressed as part of this program? Select all that apply.

Strike out with a single line and place initials

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do?

Charting by exception

A nurse working as part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team's agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

"Medical records are primarily used for communication among nurses and physicians."

After teaching a group of nursing students about the medical record and its purposes, the instructor determines that the group needs additional instruction when the students state which of the following?

Include time & date of the incident on the form

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the nursing assistant failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. Which of the following would be most appropriate for the nurse to do?

"I have a fair amount of pain near me belly incison"

The following information appears on a client's medical record: Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area. When documenting this information using the SOAP method, which of the following would the nurse document as "S"?

540 mL

The nurse is calculating the intake of the client's lunch tray. The client drank 4 ounces of juice, 6 ounces of water and 8 ounces of coffee. The correct entry on the intake and output record is:

SBAR Situational Background Assessment Recommendation

The nurse notes that the blood glucose level of a client has increased and is planning to notify the healthcare provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the healthcare provider?