Fundamentals II - Exam 1 - Practice Questions

8. The World Health Organization defines health by which of the following statements? A. "State of complete physical, mental, and social well-being, not merely the absence of disease" B. "A state of being that people define in relation to their own values, personality, and lifestyle" C. "Mental, social, and spiritual well-being" D. "All people free of disease"

A. "State of complete physical, mental, and social well-being, not merely the absence of disease"

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? A. Perform endotracheal intubation and initiate mechanical ventilation B. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth C. Administer furosemide (Lasix) 100 mg IV push stat D. Call a code for respiratory arrest

A. Perform endotracheal intubation and initiate mechanical ventilation A non-rebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A. Perform postural drainage and chest physiotherapy every 4 hours B. Allow the patient to decide whether she needs aerosolized medications C. Place the patient in a private room to decrease the risk of further infection D. Plan activities to allow at least 8 hours of uninterrupted sleep

A. Perform postural drainage and chest physiotherapy every 4 hours Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.

2. As the registered nurse, which tasks below should you NOT delegate to the LPN?* (SATA) A. Performing an assessment on a new admission B. Collecting a urine sample from an indwelling Foley catheter C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin E. Auscultating lung and bowel sounds F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain H. Providing wound care to a stage 3 pressure injury

A. Performing an assessment on a new admission C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain Answers are A, C, D, F, G....these are all out of the scope of practice for an LPN. Remember anything that deals with assessments, educating, evaluating, developing a plan of care, IV medications, unstable patients, or invasive/complex procedures where there is unpredictability the RN is responsible for doing it, and these tasks can't be delegated. An LPN can perform a focused assessment by listening to lung or bowel sounds and report the findings to the RN but a comprehensive assessment is done by the RN. In addition, the LPN can perform standard procedures that are predictable on stable patients like wound care for a pressure injury, Foley catheter insertion, obtaining an EKG, obtaining blood glucose level etc.

1. A nurse teaches the importance of folic acid to a group of pregnant women. This is considered which level of preventive care? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Illness behavior

A. Primary prevention

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? A. Suggest that the patient's oxygen be humidified B. Suggest that a simple face mask be used instead of a nasal cannula C. Suggest that the patient be provided with an extra pillow D. Suggest that the patient sit up in a chair at the bedside

A. Suggest that the patient's oxygen be humidified When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply. A. A 38-year old with moderate persistent asthma awaiting discharge B. A 63-year old with a tracheostomy needing tracheostomy care every shift. C. A 56-year old with lung cancer who has just undergone left lower lobectomy D. A 49-year old just admitted with a new diagnosis of esophageal cancer.

A. A 38-year old with moderate persistent asthma awaiting discharge B. A 63-year old with a tracheostomy needing tracheostomy care every shift. The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs.

The nurse identifies low-risk therapies to a client and should include which therapy(s) in the discussion, except? A. Acupuncture. B. Relaxation. C. Touch. D. Prayer.

A. Acupuncture. Low-risk therapies are therapies that have no adverse effects and when implementing care, can be used by the nurse who has training and experiences in their use. It includes meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures, such as prayer.

3. On your unit there are two RNs: one is a new RN while the other is an experienced RN. In addition, there are three LPNs and two nursing assistants. Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated?* (SATA) A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema. C. Empty an ostomy bag. D. Collect and record patient's blood pressure, heart rate, temperature, oxygen saturation, respirations, and pain rating. E. Assist a patient with ambulating.

A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema. Answers: A and B Option A is a task for an LPN or RN...hydrocortisone cream is a medication and the nursing assistant can't administer medications. Option B: is a task for an LPN or RN....it is a procedure. Option C, D, and E are all delegated tasks a nursing assistant can perform.

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)? A. Assisting the patient to sit up on the side of the bed B. Instructing the patient to cough effectively C. Teaching the patient to use incentive spirometry D. Auscultation of breath sounds every 4 hours

A. Assisting the patient to sit up on the side of the bed Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth admission assessment D. Initiate the nursing care plan E. Evaluate the patient's technique for using MDI's

A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient's abilities require additional education and skills. These actions are within the scope of practice of the professional RN.

HEALTH PROMOTION ACTIVITIES CAN INCLUDE: A. EXERCISE AND GOOD NUTRITION B. SMOKING AND DRINKING EXCESSIVE ALCOHOL C. UNSAFE SEX D. EXPOSURE TO AIR POLLUTANTS

A. EXERCISE AND GOOD NUTRITION

7. A client comes into the clinic for a complete physical examination. The nurse obtains a health history and determines the client is at risk for heart disease. Which of the following would lead the nurse to believe this? A. Father died of a heart attack at age 40. B. The client is 25 years old. C. The client lives near a chemical plant. D. The client works as a carpet salesman.

A. Father died of a heart attack at age 40.

An American nurse tries to speak with a Korean client who cannot understand the English language. To effectively communicate to a client with a different language, which of the following should the nurse implement? A. Have an interpreter to translate. B. Speak slowly. C. Speak loudly and closely to the client. D. Speak to the client and family together.

A. Have an interpreter to translate. Having an interpreter would be would be the best practice when communicating with a client who speaks a different language.

2. _______________ are described as a person's ideas, convictions, and attitudes about health and illness. A. Health beliefs B. Moral beliefs C. Holistic views D. Negative health behaviors

A. Health beliefs

WHEN ILLNESS DOES OCCUR, DIFFERENT ATTITUDES ABOUT ILLNESS CAUSE PEOPLE TO REACT IN DIFFERENT WAYS. MEDICAL SOCIOLOGISTS CALL THE REACTION TO ILLNESS: A. ILLNESS BEHAVIOR B. HEALTH BELIEF C. HEALTH PROMOTION D. ILLNESS PREVENTION

A. ILLNESS BEHAVIOR

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A. Observe how well the patient performs pursed-lip breathing B. Plan a nursing care regimen that gradually increases activity intolerance C. Assist the patient with basic activities of daily living D. Consult with the physical therapy department about reconditioning exercises

A. Observe how well the patient performs pursed-lip breathing Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills, appropriate to an RN.

3. Which of the following models of health or illness defines health as a positive, dynamic state, not merely the absence of disease? A. Pender's health promotion model B. Maslow's hierarchy of needs C. Rosenstoch's health belief model D. The holistic health model of nursing

A. Pender's health promotion model

A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of a headache. The patient tells the nurse that the medicines prescribed by the tribal healer have done some good. What is the appropriate response of the nurse at this time? A. Tell me about these medicines and how often you are using them. B. I advise you to refrain taking those medicines from the tribal healer. C. Could these medicines cause your headaches? D. Maybe you should increase the frequency of the healer's medicines.

A. Tell me about these medicines and how often you are using them. Asking the patient about the nature of these medicines and how often the client uses them allows the nurse to collect data about the medicines and their uses, to learn more about the practices used by this patient to improve her health, and to check for potential drug interaction before prescribing other medications or treatment. Option B: Advising the client to stop taking any nonprescription medicines is inappropriate until the nurse knows the details about all medicines used by the client. Option C: Suggesting the client's headaches are caused by the healer's medicines is inappropriate until the nurse knows details about the medicines. Option D: Telling the patient to increase the frequency of the healer's medicines is not within the practice of a nurse.

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A. Use a lift sheet when moving and positioning the patient in bed B. Use an electric razor when shaving the patient each day C. Use a soft-bristled toothbrush or tooth sponge for oral care D. Use a rectal thermometer to obtain a more accurate body temperature E. Be sure the patient's footwear has a firm sole when the patient ambulates

A. Use a lift sheet when moving and positioning the patient in bed B. Use an electric razor when shaving the patient each day C. Use a soft-bristled toothbrush or tooth sponge for oral care E. Be sure the patient's footwear has a firm sole when the patient ambulates While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.

Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration? A. Warfarin (Coumadin) 1.0 mg by mouth (PO) B. Morphine sulfate 2 to 4 mg IV C. Cephalexin (Keflex) 250 mg PO D. Heparin infusion at 900 units/hr

A. Warfarin (Coumadin) 1.0 mg by mouth (PO) Medication safety guidelines indicate that use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose, such as 10 mg. The order should be clarified before administration. The other orders are appropriate, based on the patient's diagnosis.

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. b. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

ANS: A Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement. Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency. None of the other options had equipment orsupplies listed. Avoid using generalized, empty phrases such as "status unchanged" or "had a good day." Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. "Finally, patient had no complaints" is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? a. Upon admission b. Right before discharge c. After the congestion is treated d. When the primary care provider writes the order

ANS: A Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home

A nurse has taught the staff about informatics. Which statement indicates that the staff needs more education? a. If a nurse has computer competency, the nurse is competent in informatics. b. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. c. A nurse needs to know how to acquire, critique, and apply scientific evidence from literature databases. d. Nursing informatics integrates nursing science, computer science, and information science to manage and communicate information in nursing practice

ANS: A If the staff needs more education, then an incorrect statement is made. Competence in informatics is not the same as computer competency. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. For example, you need to know how to acquire, critique, and apply scientific evidence from literature databases. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptor's best response? a. "A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care." b. "A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs." c. "A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities." d. "A change-of-shift report provides important information to caregivers and develops relationships within the health care team."

ANS: A Properly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care. Reimbursement costs and research priorities/opportunities are functions of the medical record. The purpose of the change-of-shiftreport is not to establish relationships but to ensure patient safety and continuity of care

A nurse is charting on a patient's record. Which action is most accurate legally? a. Charts legibly b. States the patient is belligerent c. Uses correction fluid to correct error d. Writes entry for another nurse

ANS: A Record all entries legibly. Do not write personal opinions. Enter only objective and factual observations of patient's behavior; quote all patient comments. For example, patient refuses to cough and deep breathe, saying, "I don't care what you say, I will not do it." Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself

A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? a. Report. b. Record. c. Consultation. d. Referral

ANS: A Reports are oral, written, or audiotaped exchanges of information among caregivers. A patient's record or chart is a confidential, permanent legal document consisting of information relevant to his or her health care. Consultations are another form of discussion in which oneprofessional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider).

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include? a. Sentinel events help determine reimbursement issues for health care. b. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. c. A clinical information system must be installed by 2014 to obtain health care reimbursement. d. HIPAA is the basis for establishing reimbursement for health care.

ANS: B Nurses' documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. Sentinel events do not determine reimbursement. About 60% of the worst types of medical errors, called sentinel events (involving death or severephysical/psychological injury), relate to communication problems that often arise during telephone reports. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; andlaboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA).

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvementwithin and across facilities. Which task did the nurse just complete? a. A focused assessment/specific body system b. The Resident Assessment Instrument/Minimum Data Set c. An admission assessment and acuity level d. An intake assessment form and auditing phase

ANS: B You assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS). This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities. A focused assessment is limited to a specific body system. An admission assessment andacuity level is performed in the hospital. An intake assessment is for home health. There is no such thing as an auditing phase

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? a. Patient went up and down stairs b. Deficient knowledge regarding crutches c. Demonstrated use of crutches d. Used crutches with no difficulties

ANS: C A second progress note method is the PIE format. The narrative note includes P—Problem, I—Intervention, and E—Evaluation. The intervention is "Demonstrated use of crutches." "Patient went up and down stairs" and "Used crutches with no difficulties" are examples of the E. "Deficient knowledge regarding crutches" is the P.

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? a. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. b. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back. c. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. d. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.

ANS: C The nurse receiving a TO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct. An examplefollows: "10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back." VO stands for verbal order, not telephone order. The doctor's name and read back must be included in the chart entry

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. "Patient seems to be in pain and states, 'I feel uncomfortable.'" b. Status unchanged, doing well c. Left abdominal incision 1 inch in length without redness, drainage, or edema d. Patient is hard to care for and refuses all treatments and medications. Family present

ANS: C Use of exact measurements establishes accuracy. Charting that an abdominal wound is "5 cm in length without redness, drainage, or edema" is more descriptive than "large wound healing well." Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as "status unchanged" or "had a good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. "Patient is hard to care for" is a personal opinion and should be avoided. It is also acritical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, "Refuses all treatments and medications."

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reviews the patient's medical record. b. The student nurse reads the patient's plan of care. c. The student nurse shares patient information with a friend. d. The student nurse documents medication administered to the patient

ANS: C When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standardshave been violated. You can review your patients' medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient's medical record and plan of care. You do notshare this information with classmates and you do not access the medical records of other patients on the unit

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? a. Focus charting using the DAR format. b. Add this data to the problem list. c. Document the variance in the patient's record. d. Report a positive variance in the next interdisciplinary team meeting.

ANS: C A variance occurs when the activities on the critical pathway are not completed as predicted, or the patient does not meet expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A type of narrative format charting is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness).

A nurse developed the following discharge summary sheet. Which critical information should be added? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a. Kardex form b. Admission nursing history c. Mode of transportation d. SOAP notes

ANS: C List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a. Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system

ANS: C One design model for Nursing Information Systems (NIS) is the protocol or critical pathway design. With this design, all health care providers use a protocol system to document the care they provide. A clinical decision support system is based on "rules" and "if-then" statements, linking information and/or producing alerts, warnings, or other information for the user. Thenursing process design is the most traditional design for an NIS. This design organizes documentation within well-established formats such as admission and postoperativeassessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) is a process by which the health care provider directly enters orders for patient care into the hospital information system.

A nurse is giving a hand-off report to the oncoming nurse. Which information is critical for the nurse to report? a. The patient had a good day with no complaints. b. The family is demanding and argumentative. c. The patient has a new pain medication, Lortab. d. The family is poor and had to go on welfare

ANS: C Relay to staff significant changes in the way therapies are to be given (e.g., different position for pain relief, new medication). Don't simply describe results as "good" or "poor." Be specific. Don't use critical comments about patient's or family's behavior, such as "Mrs. Wills is so demanding." Don't engage in idle gossip.

Which behaviors indicate that the student nurse has a good understanding of confidentialityand the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) a. Writes the patient's room number and date of birth on a paper for school b. Prints/copies material from the patient's health record for a graded care plan c. Reviews assigned patient's record and another unassigned patient's record d. Reads the progress notes of assigned patient's record e. Gives a change-of-shift report to the oncoming nurse about the patient f. Discusses patient care with the hospital volunteer

ANS: D, E When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient's record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors thatfollow HIPAA and confidentiality guidelines. Students and health care professionals may not discuss a patient's examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient's care. To protect patient confidentiality, ensurethat written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use.

When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching? A. "Everyone in my family needs to go and see the doctor for TB testing." B. "I will continue to take my isoniazid until I am feeling completely well." C. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." D. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

B. "I will continue to take my isoniazid until I am feeling completely well." Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.

7. Which patients below are best assigned to the LPN?* (SATA) A. A 30-year-old male patient with active GI bleeding that requires multiple blood transfusions. B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet. D. A 55-year-old male patient who reports chest pain and has ST segment elevation on his EKG.

B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet. Answers are B and C. LPNs should be assigned STABLE patients with predicable outcomes and cases that don't require critical thinking or complex analysis. The patients in options A and D are unstable and require constant care with decisions being based on how to interpret patient findings.

You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient. A. Remove the inhaler cap and shake the inhaler B. Open your mouth and place the mouthpiece 1 to 2 inches away C. Tilt your head back and breathe out fully D. Hold your breath for at least 10 seconds E. Press down firmly on the canister and breathe deeply through your mouth F. Wait at least 1 minute between puffs. A. A, C, B, D, E, F. B. A, C, B, E, D, F. C. C, A, B, E, D, F. D. C, A, B, D, E, F.

B. A, C, B, E, D, F. Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.

A nurse is caring for a client who has symptoms of chills, fever, no sweating, headache, nasal congestion, and stiffness and pain in the shoulders, upper back, neck, and back of the head that are common in Chinese culture and is called as syndromes of Wind. This is an example of which of the following? A. Culture shock. B. Culture-bound syndrome. C. Cultural awareness. D. Culture biased.

B. Culture-bound syndrome. Culture-bound syndrome is a combination of psychiatric and somatic symptoms that are common in one culture group or not another.

5. True or False: An RN delegates to the LPN to administer a scheduled tube feeding to a patient. The RN has now transferred full accountability to the LPN for the task getting done, and the RN is no longer accountable for the task.* A. True B. False

B. False FALSE: The RN can delegate this task to the LPN BUT the RN is still ACCOUNTABLE for the task getting done even though the RN is not the one performing it.

A Chinese-American client experiencing cough with clear white phlegm, which is believed to be a yin disorder, is likely to treat it with: A. Foods considered being yin. B. Foods considered being yang. C. Aromatherapy. D. Touch therapy.

B. Foods considered being yang. In the yin and yang theory, health is believed to exist when all aspects of the person are in perfect balance. Yin foods are cold and yang foods are hot. One eats cold foods when hot has a hot illness and one eats hot foods when one has a cold illness.

ACUTE ILLNESS AND CHRONIC ILLNESS ARE TWO GENERAL CLASSIFICATIONS OF ILLNESS. ACUTE ILLNESS REFERS TO AN ILLNESS THAT: A. IS LONGER THAN 6 MONTHS AND CAN ALSO AFFECT FUNCTIONING IN ANY DIMENSION B. HAS A SHORT DURATION AND IS SEVERE C. CAUSES AN IRREVERSIBLE CONDITION D. IS SYNONYMOUS WITH DISEASE

B. HAS A SHORT DURATION AND IS SEVERE

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? A. Reassure the patient that the ventilator will do the work of breathing for him B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm C. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning D. Insert an oral airway to prevent the patient from biting on the endotracheal tube

B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm Manual ventilation of the patient will allow you to deliver an Fio2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia.

NURSES USING THE HOLISTIC NURSING MODEL: A. UTILIZE ONLY COMPLEMENTARY INTERVENTIONS B. RECOGNIZE THE NATURAL HEALING ABILITIES OF THE BODY AND INCORPORATE COMPLEMENTARY AND ALTERNATIVE INTERVENTIONS C. CONSIDER ONLY THE MIND AND THE BODY IN PROVIDING CARE D. CONSIDER ONLY THE SPIRITUAL ASPECT IN PROVIDING CARE

B. RECOGNIZE THE NATURAL HEALING ABILITIES OF THE BODY AND INCORPORATE COMPLEMENTARY AND ALTERNATIVE INTERVENTIONS

4. When delegating you know that as an RN you must follow the 5 Rights of Delegation to make sure you are delegating properly. Select all the 5 Rights of Delegation:* (SATA) A. Right Credentials B. Right Direction/Communication C. Right Supervision D. Right Experience E. Right Task F. Right Person G. Right Patient H. Right Circumstance I. Right Time J. Right Order

B. Right Direction/Communication C. Right Supervision E. Right Task F. Right Person H. Right Circumstance The answers are: B, C, E, F, and H. The 5 Rights of Delegation are: Right Task, Right Circumstance, Right Person, Right Direction/Communication, and Right Supervision.

6. The nurse in a diabetic clinic conducts monthly seminars for diabetic clients. During these seminars, the importance of taking insulin as directed to prevent diabetic complications is emphasized. This is considered which level of preventive care? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Illness prevention

B. Secondary prevention

10. _______________ is defined as a mental self-image of strengths and weaknesses in all aspects of personality. A. Body image B. Self-concept C. Emotional change D. Family roles

B. Self-concept

To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS? A. Theophylline (Theolair, Theochron) B. Surfactant (Exosurf) C. Dexamethasone (Decadron) D. Albuterol (Proventil)

B. Surfactant (Exosurf) Exosurf neonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status, and research has show a significant decrease in the incidence of pneumothorax when it is administered.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB) B. A 68-year old just returned from bronchoscopy and biopsy C. A 72-year old who needs teaching about the use of incentive spirometry D. A 69-year old with COPD who is ventilator dependent

C. A 72-year old who needs teaching about the use of incentive spirometry Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

1. You're making the patient assignments for the next shift. On your unit there are three LPNs, two RNs, and two nursing assistants. Which patients will you assign to the LPNs?* (SATA) A. A 68 year-old male patient who is expected to be discharged home with IV antibiotic therapy. B. A 25 year-old female patient newly admitted with diabetic ketoacidosis. C. A 75 year-old male patient with dementia who has an ileostomy and scheduled tube feedings. D. A 65 year-old female patient who has a order to remove the Foley catheter.

C. A 75 year-old male patient with dementia who has an ileostomy and scheduled tube feedings. D. A 65 year-old female patient who has a order to remove the Foley catheter. Answers are C and D. Option A: An RN is the best for this patient because the patient will need discharge teaching AND the nurse will need to teach the patient how to self-administer antibiotics. Option B: This is a new admission and the patient is UNSTABLE. Most patients with DKA (diabetic ketoacidosis) require insulin drips along with close monitoring of the blood glucose levels, which requires critical thinking and interpretation. Options C and D are best for the LPNs: these are standard routine procedures the LPN can perform and these patient cases are stable.

A nurse is caring for a Chinese client who is hospitalized due to pneumonia. Based on their culture, which of the following is believed to be the cause of the illness? A. An illness is cast by an enemy. B. An illness is a result of punishment for sins. C. An illness may be attributed to overexertion. D. An illness may be given by someone who did not want it.

C. An illness may be attributed to overexertion. Illness for Chinese people may be attributed to prolonged sitting or lying or to overexertion.

A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: A. Giving any medication is not allowed. B. Surgery is strictly prohibited. C. Blood products can not be administered. D. Alternative medicines can be advised.

C. Blood products can not be administered. Among Jehovah's Witnesses, the administration of blood and blood products is prohibited.

A nurse is preparing to deliver a food tray to a Jewish client. The nurse checks the food on the tray and notes that the client has received hamburger and whole milk as a beverage. Which is the appropriate action for the nurse? A. Ask the dietary department to replace the hamburger with crabs. B. Replace the whole milk with fat-free milk. C. Call the dietary department and ask for a new meal tray. D. Deliver the designated food tray to the client.

C. Call the dietary department and ask for a new meal tray "You may not cook a young animal in the milk of its mother" -Torah says (Ex.23:19). From this, it is derived that milk and meat products may not be combined together. Not only may they not be cooked together, but they may not be served together on the same table and surely not eaten at the same time. This rule is followed observantly by the Jewish people so the appropriate nursing action is to call the dietary department to change the meal tray of the patient.

8. Select all the task you could delegate to a nursing assistant as the RN:* (SATA) A. Wound dressing change B. IV flush C. Collecting vital signs D. Weighing a patient E. Mouth care F. Suctioning a patient G. Applying oxygen to a patient H. Connecting a patient to their IV fluids I. Assisting a patient with a bath J. Applying denture paste to dentures

C. Collecting vital signs D. Weighing a patient E. Mouth care I. Assisting a patient with a bath J. Applying denture paste to dentures Answers C, D, E, I and J. These are all tasks the RN could delegate to a nursing assistant.

The nurse is providing instructions to a Chinese-American client about the frequency and dosages of the take home medicines. When conducting the teaching, the client continuously turns away from the nurse. The nurse should do which of the following appropriate action? A. Walk around the client so that the nurse can constantly face the client. B. Call the attention of the client by speaking loudly. C. Continue with the instructions, then confirming client's understanding. D. Hand over a written instruction and discuss only what the client doesn't understand.

C. Continue with the instructions, then confirming client's understanding. Most Chinese maintains a formal personal space with others, which is a form of respect. Most Chinese are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the most appropriate action is to continue with the instructions Option A: Walking around to the client so that the nurse faces the client is in direct conflict with the cultural practice. Option B: Calling the attention and speaking loudly is viewed as a rude gesture. Option D: Discussing only what the client cannot understand is not an acceptable practice of a nurse.

INTERNAL AND EXTERNAL VARIABLES CAN INFLUENCE HOW A PERSON THINKS AND ACTS. INTERNAL VARIABLES INCLUDE: A. TEMPERATURE, BLOOD PRESSURE, AND RESPIRATIONS B. ANXIETY, FEVER, RESPIRATIONS, BLOOD PRESSURE, TEMPERATURE C. DEVELOPMENTAL STAGE, INTELLECTUAL BACKGROUND, PERCEPTION OF FUNCTIONING, AND EMOTIONAL AND SPIRITUAL FACTORS D. BLADDER, HEART, LIVER, AND GALLBLADDER FUNCTIONING

C. DEVELOPMENTAL STAGE, INTELLECTUAL BACKGROUND, PERCEPTION OF FUNCTIONING, AND EMOTIONAL AND SPIRITUAL FACTORS

9. All of the following are examples of active strategies of health promotion except: A. Weight reduction B. Smoking cessation C. Fluoridation of drinking water D. Exercise training

C. Fluoridation of drinking water

PRIMARY PREVENTION AIMED AT HEALTH PROMOTION INCLUDES: A. REHABILITATION AND PREVENTION OF COMPLICATIONS B. SCREENING TECHNIQUES AND TREATING OF EARLY STAGES OF DISEASE C. HEALTH EDUCATION PROGRAMS, IMMUNIZATION, AND PHYSICAL AND NUTRITIONAL FITNESS ACTIVITIES D. CARE FOR A DIABETIC CLIENT USING INSULIN

C. HEALTH EDUCATION PROGRAMS, IMMUNIZATION, AND PHYSICAL AND NUTRITIONAL FITNESS ACTIVITIES

5. Clients maintain health or enhance their present health by routine exercise and proper nutrition. This is known as_________________. A. Wellness education B. Illness C. Health promotion D. External variables

C. Health promotion

THE HEALTH BELIEF MODEL ADDRESSES THE RELATIONSHIP BETWEEN A PERSON'S BELIEF AND BEHAVIORS, THUS: A. A PERSON WHO SMOKES DOES NOT PRACTICE THE MODEL B. A PERSON WHO DOES NOT TAKE NECESSARY MEDICATIONS DOES NOT PRACTICE THE MODEL C. IT PROVIDES A WAY OF UNDERSTANDING AND PREDICTING HOW CLIENTS WILL BEHAVE IN RELATION TO THEIR HEALTH AND HOW THEY WILL COMPLY WITH HEALTH CARE THERAPIES D. THIS MODEL PROVIDES A BASIS FOR CARING FOR CLIENTS OF ALL AGES

C. IT PROVIDES A WAY OF UNDERSTANDING AND PREDICTING HOW CLIENTS WILL BEHAVE IN RELATION TO THEIR HEALTH AND HOW THEY WILL COMPLY WITH HEALTH CARE THERAPIES

A PERSON'S BELIEFS ABOUT HEALTH ARE SHAPED IN PART BY THE PERSON'S A. CONFIDENCE IN A HEALTHCARE PROVIDER B. KNOWLEDGE OF DISEASE PROGRESSION C. KNOWLEDGE, LACK OF KNOWLEDGE, OR INCORRECT INFORMATION ABOUT ILLNESS D. CONFIDENCE IN THE HEALTHCARE SYSTEM

C. KNOWLEDGE, LACK OF KNOWLEDGE, OR INCORRECT INFORMATION ABOUT ILLNESS

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? A. An acceptance of the treatment. B. Client understanding of the preoperative procedures. C. Reflecting a cultural value. D. Client agreement to the required procedures.

C. Reflecting a cultural value. Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)? A. Discuss weight-loss strategies such as diet and exercise with the patient B. Teach the patient how to set up the BiPAP machine before sleeping C. Remind the patient to sleep on his side instead of his back D. Administer modafinil (Provigil) to promote daytime wakefulness

C. Remind the patient to sleep on his side instead of his back The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.

THIS LEVEL OF PREVENTION WOULD BE DIRECTED AT MINIMIZING COMPLICATIONS OF DISEASE A. PRIMARY PREVENTION B. SECONDARY PREVENTION C. TERTIARY PREVENTION D. ILLNESS PREVENTION

C. TERTIARY PREVENTION - tertiary prevention seeks to reduce the effects of the disease once established in an individual. ****Look up, because that sounds like secondary...? secondary prevention seeks to prevent the onset of illness

Which of the following food items would be appropriate for a Jewish client who follows a kosher diet? A. Shrimp and mussels. B. Beef and pork. C. Tuna and salmon. D. Cheese and milk.

C. Tuna and salmon. In the Jewish religion, Only fish that have scales and fins are allowed such as tuna and salmon; Option A: Shellfish such as shrimps, crabs, mussels, and lobsters are forbidden. Option B: Meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. Option D: Cheese and milk coming from animal fat are prohibited.

Which of the following clients has the lowest risk of diabetes mellitus and stroke? A. 45-year-old African-American woman. B. 35-year-old Native-American man. C. 30-year-old Hispanic-American man. D. 25-year-old Asian-American woman

D. 25-year-old Asian-American woman Among the choices, Asian Americans have the lowest risk of diabetes mellitus and stroke due to their health and dietary practices.

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.

DEFINING HEALTH IS DIFFICULT. THE WORLD HEALTH ORGANIZATION (WHO) DEFINES HEALTH AS: A. THE ABSENCE OF DISEASE B. A PERSONAL CONCEPT OF HEALTH C. REACHING FULL POTENTIAL D. A STATE OF COMPLETE PHYSICAL, MENTAL, AND SOCIAL WELL-BEING, NOT MERELY THE ABSENCE OR INFIRMITY

D. A STATE OF COMPLETE PHYSICAL, MENTAL, AND SOCIAL WELL-BEING, NOT MERELY THE ABSENCE OR INFIRMITY

6. An RN has a critical patient that needs constant monitoring. However, the RN also has other patients in need of care. Which tasks below could the RN delegate to the LPN to help continue the process of patient care?* (SATA) A. Admitting and assessing the new admission B. Completing the discharge teaching to a patient going home C. Updating and evaluating the patient's plan of care D. Administering subcutaneous Heparin E. Obtaining a routine 12-lead EKG F. Collecting a stool specimen G. Flushing a central line with normal saline

D. Administering subcutaneous Heparin E. Obtaining a routine 12-lead EKG F. Collecting a stool specimen Answers: D, E, and F...these are all tasks an LPN can perform. They are routine procedures that usually have predictable outcomes. RNs are responsible for performing assessments on new admissions, teaching, evaluating, flushing and maintain central lines, and updating the patient's plan of care.

A clinic nurse is preparing to examine a Hispanic child who was brought by the mother for his first physical check-up. While assessing the child, the nurse would avoid doing which of the following? A. Weighing the client. B. Asking the mother questions about the child. C. Having an interpreter if necessary. D. Admiring the child.

D. Admiring the child. Admiring a Hispanic-American child during the first encounter with a stranger should be avoided since this may give the child with the "evil eye" (the child will get sick). If this is done, it can be avoided by touching the child afterward.

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? A. Evaluating the patient's complaint of chest pain B. Monitoring laboratory values for changes in oxygenation C. Assessing for symptoms of respiratory failure D. Auscultating the lungs for crackles

D. Auscultating the lungs for crackles An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation, under supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.

A clinic nurse is performing an admission assessment for an African-American client scheduled for an emergency appendectomy. Which of the following questions would be inappropriate for the nurse to ask for the initial evaluation? A. Do you have any allergy to medicines? B. When did the pain start? C. Do you have any difficulty breathing? D. How close is your family during these situations?

D. How close is your family during these situations? For African-Americans, asking personal questions during the initial encounter is prohibited since it may view as a way of interfering with them.

The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these? A. Blood pressure of 152/84 mm Hg B. Respiratory rate of 27 breaths/min C. Heart rate of 92 beats/min D. Oral temperature of 101.2 F (38.4C)

D. Oral temperature of 101.2 F (38.4C) A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.

A nurse is caring a Native American client who experiences emotional distress due to a family problem. In anticipating pharmacological treatment for the client, the nurse understands that they would most likely: A. Establish the trust of the health care provider first before accepting the treatment. B. Call a clergy to ask for the religious preference of the treatment. C. Manage the emotional distress on their own to avoid disgrace. D. Resort with the use of herbal medicines with healing properties.

D. Resort with the use of herbal medicines with healing properties. Native American cultures often use a variety of herbs or other plant and root remedies. Option A: Usually Northern European American people value medicine and primary health care hence already having an established health care provider. Option B: Latin Americans offer to call clergy because of the significance of religious preference related to any illness. Option C: Asian American culture views mental illness as shameful and will keep the stress on their own to manage it.

4. All of the following are considered internal variables that influence a client's health beliefs and practices except: A. Perception of functioning B. Emotional factors C. Developmental stage D. Socioeconomic factors

D. Socioeconomic factors

When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status

D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately? A. Heart rate of 98 beats/min B. Respiratory rate of 24 breaths/min C. Blood pressure of 168/90 mm Hg D. Tympanic temperature of 101.4 F (38.6 C)

D. Tympanic temperature of 101.4 F (38.6 C) Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.

Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records? a. The nurse determines the degree to which standards of care are met by reviewing patients' health records. b. The nurse realizes that care not documented in patients' health records still qualifies as care provided. c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. d. The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

ANS: A The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, "care not documented is care not provided." The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Analysis of data from research contributes to evidence-based nursing practice and quality health care

Identify the purposes of a health care record. (Select all that apply.) a. Communication b. Legal documentation c. Reimbursement d. Education e. Research f. Nursing process

ANS: A, B, C, D, E The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.

Which situation will require the nurse to obtain a telephone order? a. As the nurse and primary care provider leave a patient's room, the primary care provider gives the nurse an order. b. At 0100, a patient's blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood. c. At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order. d. A nurse reads an order correctly as written by the primary care provider in the patient's medical record.

ANS: B A registered nurse makes a telephone report when significant events or changes in a patient's condition have occurred. Telephone orders and verbal orders usually occur at night or during emergencies. Because the time is 1 AM (0100 military time) and the primary care provider isnot present, the nurse will need to call the primary care provider for a telephone order. A verbal order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. Just reading an order that is correctly written in the chart does not require a telephone order

A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a patient enters the health care system. Which term should the nurse use to describe this system? a. Electronic medical record b. Electronic health record c. Electronic charting record d. Electronic problem record

ANS: B A unique feature of an electronic health record (EHR) is its ability to integrate all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. Although the electronic medical record (EMR) contains patient data gathered in ahealth care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably. There are no such terms as electronic charting record or electronic problem record

A nurse is discussing the advantages of standardized documentation forms in the nursinginformation system. Which advantage should the nurse describe? a. Varied clinical databases b. Reduced errors of omission c. Increased hospital costs d. More time to read charts

ANS: B Advantages associated with the nursing information system include increased time to spend with patients (not more time to read charts); better access to information; enhanced quality of documentation; reduced errors of omission; reduced, not increased, hospital costs; increasednurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to intervene? a. The new nurse uses a black ink pen to chart. b. The new nurse charts consecutively on every other line. c. The new nurse ends each entry with signature and title. d. The new nurse keeps the password secure

ANS: B Chart consecutively, line by line (not every other line); if space is left, draw a line horizontally through it, and sign your name at the end. Every other line should not be left blank. Record all entries legibly and in black ink. End each entry with your signature and title. For computer documentation, keep your password to yourself. Using black ink, ending each entry with signature and title, and keeping the password secure are all appropriate behaviors

A patient is being discharged home. Which information should the nurse include? a. Acuity level b. Community resources c. Standardized care plan d. Kardex

ANS: B Discharge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions. A patient's acuity level, usually determined by a computer program, is based on the type and number of nursinginterventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance) required over a 24-hour period. Acuity level can be used for staffing and billing. Some institutions use standardized care plans to make documentation more efficient. The plans, based on theinstitution's standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. In some settings, a Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. Most Kardex forms have an activity and treatment section and a nursing care plan section, which organize information for quick reference.

A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) a. Create a password with just letters. b. Bypass the firewall. c. Use a programmed speed-dial key when faxing. d. Implement an automatic sign-off. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information (PHI).

ANS: C, D, E, F When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. An automatic sign-off is used in mostpatient care areas and other departments that handle sensitive data. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient's name or address) must be destroyed. Most agencies have shredders or locked receptacles for shredding and later incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.

After providing care, a nurse charts in the patient's record. Which entry should the nurse document? a. Appears restless when sitting in the chair b. Drank adequate amounts of water c. Apparently is asleep with eyes closed d. Skin pale and cool

ANS: D A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, "B/P 80/50, patient diaphoretic, heart rate 102 and regular." Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as "Intake, 360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is critical for the nurse to include? a. Pupils equal and reactive to light b. The family is a "pain" c. Had poor results from the pain medication d. Sharp pain of 8 on a scale of 1 to 10

ANS: D Elements in a change-of-shift report include identification of significant changes in measurable terms (e.g., pain scale) and by observation. Report elements do not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about the patient or family, which could possibly lead to legal charges if overheard by the patient or family. This kind of language contributes to prejudicial opinions about the patient. Don't simply describe results as "good" or "poor." Be specific.

A nurse is using the source record and wants to find the daily weights. Where should the nurse look? a. Database b. Medical history and examination c. Progress notes d. Graphic sheet and flow sheet

ANS: D In a source record, the patient's chart has a separate section for each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record data. Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs, dailyweights, and intake and output. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, the nurse's admission history and ongoing assessment, the dietitian's assessment, laboratory reports, radiologic test results). In the source record, the medical history and examination contain results of the initial examination performed by the physician, including findings, family history, confirmed diagnoses, and medical plan of care. In the source record, the progress notes contain an ongoing record of the patient's progress and response to medical therapy and a review of the disease process; it often is interdisciplinaryand includes documentation from health-related disciplines (e.g., health care providers, physical therapy, social work).

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record? a. Nursing process form b. Step-by-step skills manual c. A list of possible procedures d. Reports to third party payers

ANS: D Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record

Which entry will require follow-up by the nurse manager? 0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on. ------------------- Jane More, RN0810 Notified primary care provider of patient's status. New orders received. ------------------- Jane More, RN0815 Portable x-ray of L hip taken in room. States, "I feel fine." ------------------- Jane More, RN0830 Incident report completed and placed on chart. ------------------- Jane More, RN a. 0800 b. 0810 c. 0815 d. 0830

ANS: D Note that you do not include mention of the incident report in the patient's medical record. Instead you document in the patient's medical record an objective description of what happened, what you observed, and follow-up actions taken. It is important to evaluate anddocument the patient's response to the error or incident. Always contact the patient's health care provider whenever an incident happens

A nurse wants to reduce data entry errors on the computer system. Which behavior should thenurse implement? a. Use the same password all the time. b. Share password with only one other staff member. c. Print out and review computer nursing notes at home. d. Chart on the computer immediately after care is provided.

ANS: D To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected from a patient. A good system requires frequent and randomchanges in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy (e.g., shred) anything that is printed when the information is no longer needed. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality.