Download Nursing Documentation and Medication Administration and more Exams Nursing in PDF only on Docsity!
Nursing practice Exam 3 1st semester 134 Questions with
Verified Answers
A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? a) Study the discharge plan. b) Check the graphic data for vital signs. c) Examine the history and physical examination. d) Look for an advance directive. - CORRECT ANSWER ANS: D The advance directive, which should be located in a special section of the patient's medical record, should be examined first because the patient's symptoms indicate that he may need to be resuscitated. The advance directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data record assessment should be done frequently, such as vital signs. The history and physical examination provide a detailed summary of the patient's current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data. A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? a) It involves a cooperative effort among various disciplines. b) The system requires diligence in maintaining a current problem list. c) Data may be fragmented and scattered throughout the chart.
d) It allows the nurse to provide information in an unorganized manner. - CORRECT ANSWER ANS: C A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner. A student nurse makes the following comments to her preceptor: "I love getting information from the chart. Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system? a) Narrative b) Focus c) Source oriented d) Problem oriented - CORRECT ANSWER ANS: D Narrative charting is a free text description of the patient status and nursing care, not usually organized according to patient problems. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. Source- oriented record systems require members of each discipline to record their findings in a separately labeled section of the chart. A problem-oriented record system is organized around the patient's problems and each member of the healthcare team document in the area designated for that problem. This method makes it easier to view the patient's progress and integrate the interdisciplinary perspective. The department of nursing at a local hospital is considering changing to charting by exception (CBE). A major disadvantage of CBE is that it: a) Increases the time nurses spend on charting in narrative format b) Does not clearly identify deviations from normal expectations
Postoperative colon resection d) Follow all three plans - CORRECT ANSWER ANS: C The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient's other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care, or individualized nursing diagnoses and interventions may be integrated into the plan.
- The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? a) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN b) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN c) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain V.O.: Dr. D. Kelly/Kay Andrews, RN d) 09/02/16 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN - CORRECT ANSWER ANS: B Correct documentation of a telephone order is as follows: "09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN" (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber's name and title, nurses name and title.) The other options demonstrate incomplete documentation of a telephone order. A patient refuses a dose of medication. How should the nurse document the event? a) Patient is uncooperative and refuses the prescribed dose of digoxin. b) Patient refuses the 0900 dose of digoxin.
c) Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. d) 0900 dose of digoxin not given. - CORRECT ANSWER ANS: B "Patient refuses the 0900 dose of digoxin" objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. "0900 dose of digoxin not given," provides no explanation why the medication was not given. The other two options offer judgmental information, which should be avoided when charting. At 1000 on 11/14/16, the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? a) 11/14/16 at 1200 b) 11/14/16 at 2200 c) 11/15/16 at 1000 d) 11/16/16 at 1000 - CORRECT ANSWER ANS: C The prescriber must countersign all verbal and telephone orders within 24 hours. The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? a) Repeat the order to the prescriber even if she believes she understood the order correctly. b) Immediately notify the pharmacy of the order and verify it with a pharmacist. c) Ask the unit secretary to listen to the prescriber on the phone to verify the order. d) Transcribe the order on notepaper and verify the dosage in a drug handbook. - CORRECT ANSWER ANS: A
a) The Minimum Data Set (MDS) for assessment b) Situation-Background-Assessment-Recommendation (SBAR) for reporting c) Health Care Financing Administration guidelines prior to surgery d) The Joint Commission guidelines for discharge planning - CORRECT ANSWER ANS: A Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a handoff report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities. However, only the MDS assessment is mandated by federal law. The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse: a) Performs oral care b) Assists the patient out of bed c) Assists the patient with bathing d) Changes the patient's operative dressings - CORRECT ANSWER ANS: B OOB is the abbreviation for "out of bed." The nurse is following the physician's order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patient's postoperative dressings. Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? "When taking off the provider's orders, you should: a) Write drug names in full—rather than using abbreviations"
b) Use apothecary units—instead of metric units" c) Write 'at' or 'each'—rather than use the '@'symbol" d) Write 'mL' or 'milliliters'—in place of the 'cc' abbreviation" - CORRECT ANSWER ANS: B The student nurse should question the instruction to use apothecary units— instead of metric units. Nurses are encouraged to use metric units instead of the rarely used apothecary system. The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? a) "Occurrence reports track problems and identify areas for quality improvement." b) "Occurrence reports are required by the Food and Drug Administration (FDA) to report drug errors." c) "The Joint Commission requires occurrence reports for all client falls." d) "Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence." - CORRECT ANSWER ANS: A Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or The Joint Commission. Which of the following is the most beneficial aspect of electronic documentation systems? a) Assist collaboration b) Provide cautionary reminders c)
What is one advantage of problem-intervention-evaluation (PIE) charting? a) Focuses on a complete list of client problems b) Assesses the client in a comprehensive manner c) Documents the planning portion of the client's care d) Establishes an ongoing plan of care for the client - CORRECT ANSWER ANS: D The PIE charting format organizes information by the client's problems and requires a daily assessment record and progress notes, thus eliminating the need for a nursing care plan. It documents, in a comprehensive manner, the client information. It does not assess the client. A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. This type of charting is a form of: a) Narrative charting b) Charting by inclusion c) Charting by exception d) Source oriented charting - CORRECT ANSWER ANS: C Charting by exception is a system of charting where only exceptions to the normal findings or to the unit standards are charted. These are directed by organizational, professional, and legal guidelines. Narrative charting records all findings, normal and abnormal. Charting by inclusion is not discussed in the text. Source-oriented charting refers to each healthcare practitioner's charting in a specific section of the chart. For example, nurses would document in the nurses' notes section and physicians would document in the physician section of the healthcare record. At the end of a 12-hour shift, the nurse gives a verbal report to the oncoming nurse. This face-to-face reporting, using the acronym "CUBAN," does which of the following?
a) Ensures that the nurse is able to finish the shift as quickly as possible b) Provides a guide for the nurse's report to the oncoming nurse c) Requires the nurses to engage in walking rounds for the report d) Provides a detailed cultural report for Latino patients - CORRECT ANSWER ANS: B The CUBAN acronym is used in all types of report formats and stands for Confidential, Uninterrupted, Brief, Accurate, Named nurse. Following this format, the nurse giving report has a guide to remember the important data that need to be shared with the oncoming nurse who will care for the patient. Report should not be rushed in order for a nurse to finish the shift as quickly as possible. However, the nurse should try to begin report before the shift is over, early enough to complete report before the next shift begins. The CUBAN approach does not require walking rounds. The CUBAN acronym can be used for report about any patient regardless of race, ethnicity, or religion and does not necessarily provide cultural information. It is not specific to Latino patients. The instructor is teaching the nursing students about electronic health records (EHR). Which student statement indicates the need for further instruction? a) "I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it." b) "The EHR integrates the patient's health information documented by the entire healthcare team into one electronic system." c) "The EHR can track problems and errors, which can direct quality improvement efforts in a given institution." d) "I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution." - CORRECT ANSWER ANS: D The EHR can vary according to institution and is employed through integrative technology for the entry of data from all healthcare professionals. Although a student knows how to use a computer, this knowledge may not directly translate so that the student is able to accurately document in any particular institution. A
providers and the manner in which they document using narrative charting; longer time spent in documenting client progress; and a decrease in interdisciplinary discussion of client progress owing to lengthy and redundant documentation by healthcare team members. Which statement(s) by the student nurse indicates an understanding of the nursing Kardex? Select all that apply. a) "It pulls data from multiple areas of the patient's chart." b) "It is usually kept at the patient's bedside." c) "It is used to document patient response to interventions." d) "It summarizes the plan of care and guides nursing care." - CORRECT ANSWER ANS: A, D The Kardex is a tool that pulls data from multiple areas of the patient's health record and helps guide nursing care. Responses to interventions are documented on flowsheets and in nurses' notes. Kardexes are paper forms that are kept together in a portable file at the nurses' station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there as a general rule. Which action by the nurse breaches patient confidentiality? Select all that apply. a) Leaving patient data displayed on a computer screen where others may view it b) Remaining logged on to the computer system after documenting patient care c) Faxing a patient report to the nurses' station where the patient is being transferred d) Informing the nurse manager of a change in the patient's condition - CORRECT ANSWER ANS: A, B Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses' station receiving a patient
does not breach patient confidentiality because it is located at the nurses' station out of others' view. Anyone directly involved in the patient's care has the right to know about the patient's condition without breaching patient confidentiality. Which statement(s) by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. a) "I can wait until the end of the shift to document my care." b) "Charting every 2 hours is the most appropriate way to document nursing care." c) "I find it easier to chart before I go to lunch, and then after my shift report." d) "I should chart as soon as possible after nursing care is given." - CORRECT ANSWER ANS: A, B, D Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or report after the shift is over is too long a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report. The implementation of electronic health records (EHRs) allows the nurse to do which of the following? Select all that apply. a) Use trend data to facilitate evidence-based nursing practice b) Promote efficient use of time spent charting c) Reduce the opportunity for interdisciplinary collaboration d) Activate the system's safeguards to promote client safety - CORRECT ANSWER ANS: A, B, D The implementation of electronic health records (EHR) has many advantages for the nurse. These include the ability to identify trends in data to facilitate
A complete discharge summary must be completed even if a complete verbal transfer report is given to ensure that all important and specific information is communicated to another healthcare provider when the client is discharged from the hospital. It is important for every client for ongoing care and documentation while the client is in the community. A verbal transfer report is not a replacement for the comprehensive discharge record; it can be done in the EMR formats, a narrative note, or on a discharge summary form. The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range. The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. The correct nursing actions at this time are below. Select all that apply. a) Notify the prescriber before giving the medication. b) Give subcutaneous heparin as ordered. c) Hold the medication dose at this time. d) Chart the reason the medication was not given. e) Assess for other significant signs and symptoms. f) Record abnormal findings in the patient's health record. - CORRECT ANSWER ANS: C, D, E, F Heparin, an anticoagulant, should be given to achieve one and a half to two times the normal clotting times and PTT. Because the findings of the laboratory values are four times the normal range and petechiae are present, this indicates a significant risk for bleeding. Therefore, the heparin should be held; the physician should be notified immediately. The nurse must document why the medication was not given and should assess for other significant findings. Omitted or delayed administration must be charted as soon as possible with an explanation for the delay or omission. The nurse will notify the provider but not give the medication. Heparin is given via a subcutaneous injection; however, because it is being held, it will not be administered or documented as "given." Because the findings
regarding the heparin and its use are abnormal, the nurse would not document normal findings. The electronic health record (EHR) is used to document client care management. Which statement(s) below is/are applicable to EHR? Select all that apply. a) Increases the potential for breaches in confidentiality b) Decreases the time spent to complete documentation c) Minimizes medical errors through use of alert systems d) Communicates the client's plan of care to the healthcare team - CORRECT ANSWER ANS: B, C, D The EHR streamlines many documentation steps, making written communication concise and standardized. Electronic access to the patient's health record increases confidentiality and security of information by using customized passwords for each healthcare professional to limit access to the records. Time for documentation is decreased as the nurse becomes more comfortable using electronic documentation. Medical errors are decreased owing to programmed alerts that are automatically displayed when a healthcare provider takes an action that could potentially be harmful to the client. The EHR facilitates communication of client care across the healthcare team because all of the information is in one place and multiple people can access it from different computers at the same time. The nurse administered the narcotic Demerol, 50 mg PO at 1400 to a patient with pain rated as 9 on a 0 to 10 scale. At 1430, the patient stated that the medication was not working and requested to have morphine IV, which the provider had prescribed for severe pain. What is the nurse's best evaluation of this situation? a) The patient needs to understand that it takes time for the medication to reduce pain. b) Administering Demerol PO was not the best nursing intervention in this situation. c) The provider should be notified if the patient's pain is not relieved in 2 hours.
d) Clarify the dose and route with the surgeon. - CORRECT ANSWER ANS: D The nurse should contact the surgeon to clarify the dosage and route of administration. Heparin is measured in units and administered either subcutaneously or intravenously. The nurse should contact the provider who prescribed the medications. A patient is having pain and has requested a dose of analgesic medication. The medication administration record indicates that he prescribed the narcotics hydromorphone (Dilaudid) intramuscularly and morphine sulfate intravenously. Where should the nurse first assess to determine which medication to administer? a) The patency of the IV site b) Which drug the patient prefers c) The patient's pain level d) Skin integrity of the dorsogluteal site - CORRECT ANSWER ANS: C The nurse should check the patient's pain level. If the pain is severe, the nurse should administer IV morphine to provide the patient immediate relief. The dorsogluteal site for IM injections should be avoided. Which term refers to the movement of a drug from the site of administration to the bloodstream? a) Absorption b) Distribution c) Metabolism d) Excretion - CORRECT ANSWER ANS: A Absorption refers to the movement of drug from the site of administration into the bloodstream. Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. Metabolism is the biotransformation of
the drug into a more water-soluble form or into metabolites that can be excreted from the body. Excretion, or the removal of drugs from the body, takes place in the kidneys, liver and gastrointestinal tract, lungs, and exocrine glands. A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief? a) Liquid acetaminophen with codeine b) Intravenous morphine sulfate c) Intramuscular meperidine d) Oral oxycodone tablets - CORRECT ANSWER ANS: B Drugs administered by the intravenous route are injected directly into the bloodstream and do not have to be absorbed into it. Therefore, they act more quickly than drugs administered by the oral or intramuscular routes. A nurse is being investigated for stealing narcotics from several patients. Which federal agency can become involved in the investigation of this incident? a) State Board of Nursing b) U.S. Food and Drug Administration c) U.S. Drug Compliance Department d) U.S. Drug Enforcement Agency - CORRECT ANSWER ANS: D The U.S. Drug Enforcement Agency (DEA) can investigate diversion and theft of controlled substances. The State Board of Nursing is not a federal agency and is only empowered to discipline a nurse's license. The U.S. Food and Drug Administration regulates the testing, sale, and manufacture of drugs. A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug?
