Test Bank For Clinical Nursing Skills and Techniques 11th Edition by Anne Griffin Perry, Exams of Nursing

Download Test Bank For Clinical Nursing Skills and Techniques 11th Edition by Anne Griffin Perry and more Exams Nursing in PDF only on Docsity! Test Bank For Clinical Nursing Skills and Techniques 11th Edition by Anne Griffin Perry, Patricia A. Potter Chapter 1 - 43 Complete his is a bank of tests (study questions) to = “help you a Tana LiL} —— di = Fae | test after Gai Nig ds, all SK , re, ae DOWNLOAD Table Of Content Chapter 1. Using Evidence in Nursing Practice Chapter 2. Communication and Collaboration Chapter 3. Admitting, Transfer, and Discharge Chapter 4. Documentation and Informatics Chapter 5. Vital Signs Chapter 6. Health Assessment Chapter 7. Specimen Collection Chapter 8. Diagnostic Procedures Chapter 9. Medical Asepsis Chapter 10. Sterile Technique Chapter 11. Safe Patient Handling and Mobility (SPHM) Chapter 12. Exercise and Mobility Chapter 13. Support Surfaces and Special Beds Chapter 14. Patient Safety Chapter 15. Disaster Preparedness Chapter 16. Pain Management Chapter 17. End-of-Life Care Chapter 18. Personal Hygiene and Bed Making Chapter 19. Care of the Eye and Ear Chapter 20. Safe Medication Preparation Chapter 21. Nonparenteral Medications Chapter 22. Parenteral Medications Chapter 23. Oxygen Therapy Chapter 24. Performing Chest Physiotherapy Chapter 25. Airway Management Chapter 26. Cardiac Care Chapter 27. Closed Chest Drainage Systems Chapter 28. Emergency Measures for Life Support Chapter 29. Intravenous and Vascular Access Therapy Chapter 30. Blood Therapy Chapter 31. Oral Nutrition Chapter 32. Enteral Nutrition Chapter 33. Parenteral Nutrition Chapter 34. Urinary Elimination Chapter 35. Bowel Elimination and Gastric Intubation Chapter 36. Ostomy Care Chapter 37. Preoperative and Postoperative Care Chapter 38. Intraoperative Care c. CHOICE BLANK d. O. Cc C = Comparison of interest. What standard of care or current intervention do you usually use now in practice? P = Patient population of interest. Identify your patient by age, gender, ethnicity, disease, or health problem. | = Intervention of interest. What intervention (e.g., treatment, diagnostic test, and prognostic factor) do you think is worthwhile to use in practice? O = Outcome. What result (e.g., change in patient's behavior, physical finding, and change in patient’s perception) do you wish to achieve or observe as the result of an intervention? DIF: CognitiveLevel: Knowledge OBJ: Develop a PICO question. TOP: PICO KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) . A well-developed PICOT question helps the nurse: a. search for evidence. b. include all five elements of the sequence. c. find as many articles as possible in a literature search. d. accept standard clinical routines. The more focused a question that you ask is, the easier it is to search for evidence inthe scientific literature. A well-designed PICOT question does not have to include all five elements, nor does it have to follow the PICOT sequence. Do not be satisfied with clinical routines. Always question and use critical thinking to consider better ways to provide patient care. DIF: CognitiveLevel: Analysis OB): Describe the six steps of evidence- based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) . The nurse is not sure that the procedure the patient requires is the best possible for the situation. Utilizing which of the following resources would be the quickest way to review research on the topic? a. CINAHL b. PubMed c. MEDLINE d. The Cochrane Database D The Cochrane Community Database of Systematic Reviews is a valuable source of synthesized evidence (i.e., pre-appraised evidence). The Cochrane Database includes the full text of regularly updated systematic reviews and protocols for reviews currently happening. MEDLINE, CINAHL, and PubMed are among the most comprehensive databases and represent the scientific knowledge base of health care. DIF: CognitiveLevel: Synthesis OB): Describe the six steps of evidence- based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 6. The nurse is getting ready to develop a plan of care for a patient who has a specific need. The best source for developing this plan of care would probably be: a. The Cochrane Database. b. MEDLINE. c. NGC. d. CINAHL. ANSWER: C The National Guidelines Clearinghouse (NGC) is a database supported by the Agency for Healthcare Research and Quality (AHRQ). It contains clinical guidelines—systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population. The NGC is a valuable source when you want to develop a plan of care for a patient. The Cochrane Community Database of Systematic Reviews, MEDLINE, and CINAHL are all valuable sources of synthesized evidence (i.e., pre-appraised evidence). DIF: CognitiveLevel: Synthesis OB): Describe the six steps of evidence- based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 7. The nurse has done a literature search and found 25 possible articles on the topic that she is studying. To determine which of those 25 best fit her inquiry, the nurse first should look at: a. the abstracts. b. the literature reviews. c. the —Methodsl sections. d. the narrative sections. An abstract is a brief summary of an article that quickly tells you whether the article is research based or clinically based. An abstract summarizes the purpose of the study or clinical query, the major themes or findings, and the implications for nursing practice. The literature review usually gives you a good idea of how past research led to the researcher's question. The —Methodsl or —Designi section explains how a research study is organized and conducted to answer the research question or to test the hypothesis. The narrative of a manuscript differs according to the type of evidence-based article—clinical or research. DIF: CognitiveLevel: Application OB): Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 8. The nurse wants to determine the effects of cardiac rehabilitation program attendance on the level of postmyocardial depression for individuals who have had a myocardial infarction. The type of study that would best capture this information would be a: randomized controlled trial. b. qualitative study. c. case control study. d. descriptive study. im Qualitative studies examine individuals‘ experiences with health problems and the contexts in which these experiences occur. A qualitative study is best in this case of an individual nurse who wants to examine the effectiveness of a local program. Randomized controlled trials involve close monitoring of control groups and treatment groups to test an intervention against the usual standard of care. Case control studies typically compare one group of subjects with a certain condition against another group without the condition, to look for associations between the condition and predictor variables. Descriptive studies focus mainly on describing the concepts under study. DIF: CognitiveLevel: Synthesis OB): Discuss ways to apply evidence in nursing practice. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) . Six months after an early mobility protocol was implemented, the incidence of deep vein thrombosis in patients was decreased. This is an example of what stage in the EBP process? a. Asking a clinical question b. Applying the evidence c. Evaluating the practice decision d. Communicating your results Cc After implementing a practice change, your next step is to evaluate the effect. You do this by analyzing the outcomes data that you collected during the pilot project. Outcomes evaluation tells you whether your practice change improved conditions, created no change, or worsened conditions. DIF: CognitiveLevel: Application OB): Discuss ways to apply evidence in nursing practice. TOP: Evidence- Based Practice KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment (safety and infection control) MULTIPLE RESPONSE . To use evidence-based practice appropriately, you need to collect the most relevant and best evidence and to critically appraise the evidence you gather. This process also includes: (Select all that apply.) a. asking a clinical question. b. applying the evidence. c. evaluating the practice decision. d. communicating your results. ANSWERIA, B, C, D EBP comprises six steps (Melnyk and Fineout-Overholt, 2010): 1. Aska clinical question. 2.Search for the most relevant and best evidence that applies to the question. 3.Critically appraise the evidence you gather. 4.Apply or integrate evidence along with one’s clinical expertise and patient preferences and values in making a practice decision or change. 5.Evaluate the practice decision or change. 6.Communicate your results. A research article includes a section that explains whether the findings from the study have —clinical implications. The researcher explains how to apply findings in a practice setting for the types of subjects studied. DIF: CognitiveLevel: Application OB): Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 6. is the extent to which a study’‘s findings are valid, reliable, and relevant to your patient population of interest. ANS: Scientific rigor Scientific rigor is the extent to which a study’‘s findings are valid, reliable, and relevant to your patient population of interest. DIF: CognitiveLevel: Application OBJ: Define the key terms listed. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 7. Patient fall rates are an example of an ANS: outcome measurement Data collected within a health care agency offer important trending information about clinical conditions and problems. Staff in the agency review the data periodically to identify problem areas and to seek solutions. DIF: CognitiveLevel: Application OBJ: Define the key terms listed. TOP: Quality Improvement KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) Chapter 02: Communication and Collaboration Perry et al.: Clinical Nursing Skills & Techniques, 11th Edition MULTIPLE CHOICE 1. The patient is a 54-year-old man who has made a living as a construction worker. He dropped out of high school at age 16 and has been a laborer ever since. He never saw any need for —book learning, and has lived his life —my wayl since he was a teenager. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of —fast foodi while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure? a. —The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue. b. —There may be a blockage of one of the arteries in your heart, causing the chest discomfort. He needs to know where it is to see how he can treat it.! c. —We have pamphlets here that can explain everything. Let me get you one. | d. —It's just like a clogged pipe. All the doctor has to do is _Roto-Rooter’ it to get it cleaned out.| B To send an accurate message, the sender of verbal communication must be aware of different developmental perspectives as well as cultural differences between sender and receiver, such as the use of dialect or slang. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Verbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity . The nurse is assessing a patient who says that she is feeling fine. The patient, however, is wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways? a. —You seem anxious today. Is there anything on your mind?! b. —I‘m glad you're feeling better. I'll be back later to help you with your bath.| c. —l can see you're upset. Let me get you some tissue.| d. —It looks to me like you're in pain. I‘ll get you some medication.! When assessing a patient’s needs, assess both the verbal and the nonverbal messages and validate them. In this case, if you see a patient wringing her hands and sighing, it is appropriate to ask, —You seem anxious today. Is there anything on your mind?I It is not enough to accept only the verbal message if nonverbal signals conflict, and it is inappropriate to jump to conclusions about what the nonverbal signals mean. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity . Nonverbal communication incorporates messages conveyed by: a. touch. b. cadence. c. tone quality. d. use of jargon. Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. Cadence, tone quality, and the use of jargon are all part of verbal communication. DIF: CognitiveLevel: Knowledge OBJ: Explain the communication process. TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity . The patient is an elderly male who had hip surgery 3 days ago. He states that his hip hurts, but he does not like how the medicine makes him feel. He believes that he can tolerate the pain better than he can tolerate the medication. What would be the best response from the nurse? 9: 10. Ts The patient is an elderly man who was brought to the hospital from an assisted-living community with complaints of anorexia and general malaise. The nurse at the assisted-living community reported that the patient was very ritualistic in his behavior and fastidious in his dress and always took a shower in the evening before bed. The patient became very angry and upset when the patient care technician asked him to take his bath in the morning. What does this behavior tell the nurse? a. The patient is exhibiting anxiety because of a change in his rituals. b. The patient is suffering from sensory overstimulation. c. The patient is basically an angry person. d. The patient has to follow hospital protocol. Patients often become ritualistic and intent on performing activities a certain way. Anxiety develops as a result of a specific event or a general pattern of change. DIF: CognitiveLevel: Analysis OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Gerontological Considerations—Anxiety KEY: Nursing Process Step: Diagnosis © MSC: NCLEX: Psychosocial Integrity The nurse is preparing to give an intramuscular injection to the patient in room 320. The patient care technician comes to the medication room and tells the nurse that the patient in room 316 is very angry with his roommate and is threatening to hit him. How should the nurse respond? a. Tell the patient care technician to calm the patient down until she can get there. b. Have the angry patient’s roommate moved to another location. c. Tell the angry patient to calm down until she can get there. d. Tell the angry patient that he has to act civilized in the hospital, and that’s that. B A potentially violent patient needs to be in an environment with decreased stimuli and to have protection from injury to self and against others. Encourage other people, particularly those who provoke anger, to leave the room or area. De-escalation is a skill that cannot be delegated to nursing assistive personnel (NAP). DIF: CognitiveLevel: Application OB): Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity Which behavior should the nurse who is communicating with a potentially violent patient employ? a. Sit closer to the patient. b. Speak loudly and firmly. c. Use slow, deliberate gestures. d. Always block the door to prevent escape. ANSWER: C 12. 13; Make sure that gestures are slow and deliberate rather than sudden and abrupt. There is less chance for misinterpretation of the message, and slow, deliberate gestures are less threatening. Keep an adequate distance between yourself and the patient to reduce your risk of injury and to avoid making the patient feel pressured. Try to talk ina comfortable, reassuring voice. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit; if the patient feels unable to escape, this may cause a violent outburst. DIF: CognitiveLevel: Application OB): Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity The patient is sitting at the bedside. He has not been eating and is just staring out of the window. The nurse approaches the patient and asks, —What are you thinking about?I What type of communication technique is this? a. Restating b. Clarification c. Broad openings d. Reflection Cc Broad openings encourage patients to select topics for discussion. They affirm the value of the patient's initiative. Restating is repeating a main thought that the patient has expressed. Clarification is attempting to put into words vague ideas or asking the patient to explain what he or she means. Reflection is directing back to the patient ideas, feelings, questions, or content. DIF: CognitiveLevel: Knowledge OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis © MSC: NCLEX: Psychosocial Integrity A patient tells the nurse, —I want to die. Which response is the most appropriate for the nurse to make? a. —Why would you say that?l b. —Tell me more about how you are feeling. c. —The doctor should be told how you feel. | d. —You have too much to live for to think that way. ANSWER: B Broad openings encourage the patient to select topics for discussion and indicate acceptance by the nurse and the value of the patient's initiative. —wWhyI questions can cause defensiveness and can hinder communication. Saying you will inform the doctor leads the conversation away from the patient’s feelings. Saying the patient has too much to live for is false reassurance and negates the patient's feelings. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 14. 15. 16. The patient states, —I| don‘t know what my family will think about this. The nurse wishes to use the communication technique of clarification. Which of the following statements would fit that need best? a. —You don‘t know what your family will think?! b. —I‘m not sure that | understand what you mean. c. —I think it would be helpful if we talk more about your family.! d. —l sense that you may be anxious about something.| B The definition of clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse‘s understanding, or asking the patient to explain what he or she means. Repeating main thoughts expressed by patients is known as —restating.I Using questions or statements that help patients expand on a topic of importance is known as —focusing.| Asking a patient to verify the nurse‘s understanding of what the patient is thinking or feeling is known as —sharing perceptions. | DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity A patient tells the nurse, —I think that | must be really sick. All of these tests are being done.| Which response by the nurse uses the specific communication technique of reflection? a. —l sense that you are worried.| b. —I think that we should talk about this more.| c. —You think that you must be very sick because of all the tests.| d. —l‘ve noticed that this is an underlying issue whenever we talk.! Cc Reflecting is directing back to the patient ideas, feelings, questions, or content, validating the nurse‘s understanding of what the patient is saying, and signifying empathy, interest, and respect for the patient. Asking the patient to confirm your sense of his or her anxiety is —sharing perceptions. Stating that —we should talk about this more,| that is, putting forth questions or statements to expand on a topic, is —focusing.| Pointing out underlying issues or problems that occur repeatedly is known as —theme identification. | DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity The patient is admitted to the hospital with complaints of headache, nausea, and dizziness. She states that she has a final exam in the morning and needs to do well on it to pass the course, but she can‘t seem to get into it. She appears nervous and distracted, and is unable to recall details. She most likely is showing manifestations of___anxiety. a. mild b. moderate c. severe d. panic state of ANSWER: C depressed patients. TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 1. The nurse is starting her first set of morning rounds. As she interacts with the patient, her questions revolve around his reactions to his disease process. She also asks if there is anything that she can do to make him more comfortable. This type of interaction is known as ANS: therapeutic communication Therapeutic communication is an application of the process of communication to promote the well-being of the patient. DIF: CognitiveLevel: Analysis OB): Identify guidelines to use in therapeutic communication. TOP: Therapeutic Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. An active process of receiving information that nonverbally communicates to the patient the nurse‘s interest and acceptance is classified as___. ANS: listening Definition: An active process of receiving information and examining one’s reaction to messages received. Therapeutic value: Nonverbally communicates to the patient the nurse‘s interest and acceptance. DIF: CognitiveLevel: Knowledge OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 3. The patient is talking about his fear of having surgery but is being vague and is using a lot of jargon. The nurse states, —I‘m not sure what you mean. Could you tell me again?i This is an example of. . ANS: clarification Clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. This may help to clarify the patient’s feelings, ideas, and perceptions, and may provide an explicit correlation between them and the patient‘s actions. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. Directing the conversation back to patient ideas, feelings, questions, or content is known as ANS: reflection Reflection or directing back to the patient ideas, feelings, questions, or content validates the nurse‘s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient. DIF: CognitiveLevel: Knowledge OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 5. The patient tells the nurse that his mother left him when he was 5 years old. The nurse responds by saying, —You saythat your mother left you when you were 5 years old?ll This is an example of. . ANS: restating Restating is a technique whereby the nurse repeats the main thought that the patient has expressed. It indicates that the nurse is listening, and validates, reinforces, or calls attention to something important that has been said. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The patient has been agitated for the entire morning but refuses to say why he is angry. Instead, whenever the nurse speaks to him, he smiles at her while clenching his fist at the same time. The nurse states, —I can see that you’re smiling, but | sense that you are really very angry.| This is an example of : ANS: sharing perceptions Sharing perceptions is asking the patient to verify the nurse‘s understanding of what the patient is thinking or feeling. It conveys to the patient the nurse‘s understanding and has the potential for clearing up confusing communication. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. Lack of verbal communication for a therapeutic reason is known as. ANS: therapeutic silence Lack of verbal communication for a therapeutic reason is known as therapeutic silence. It allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse‘s support, understanding, and acceptance. DIF: CognitiveLevel: Comprehension OB): Explain the communication process. TOP: Therapeutic Silence KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 8. Anxiety that is the source of inattention, decreased perceptual field, and diaphoresis is classified as : ANS: moderate anxiety Moderate anxiety is characterized by selective inattention, decreased perceptual field, the ability to focus only on relevant information, muscle tension, and/or diaphoresis. DIF: CognitiveLevel: Comprehension OB): Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity Chapter 03: Admitting, Transfer, and Discharge Perry et al.: Clinical Nursing Skills & Techniques, 11th Edition MULTIPLE CHOICE 1. The patient is scheduled to go home after having coronary angioplasty. What would be the most effective way to provide discharge teaching to this patient? a. Provide him with information on health care websites. b. Provide him with written information on what he has to do. a Sit and carefully explain what is required before his follow-up. d. Use a combination of verbal and written information. ANSWER: D For discharge teaching, use a combination of verbal and written information. This most effectively provides patients with standardized care information, which has been shown to improve patient knowledge and satisfaction. b. Request and wait for an interpreter. c. Work with the family to gather information. d. Complete as much of the admission assessment as possible using simple phrases. ANSWER: B If the patient does not speak English or has a severe hearing impairment, the clerk must have access to an interpreter to assist during the admission procedure. Translation services are preferable to using family members to ensure correct translation of medical terminology. Hand gestures and simple phrases may not be adequate for everything that will be discussed at the time of admission. DIF: CognitiveLevel: Application OB): Describe the nurse’s role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: The Patient Who Does Not Speak English KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment . The patient has been admitted to the emergency department after being beaten and raped. She is agitated and is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her? a. She is safe in the hospital, and she needs to provide her name. b. She can be admitted to the hospital without anyone knowing it. Her records will be used as evidence in the trial. a d. Since she has come to the hospital, she has to be examined by the doctor. ANSWER: B A patient who has been a victim of crime can be admitted anonymously under an agency's —blackoutl or —do not publish! procedure. HIPAA places limits on the institution‘s ability to use or disclose the patient’s PHI. The Patient Self- Determination Act prohibits the hospital from requiring her to submit to an examination. DIF: CognitiveLevel: Analysis OB): Describe the nurse's role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: Victim of Crime KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity . The patient is admitted to the ICU after having been in a motor vehicle accident. He was intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on: a. examining the patient and treating the pain. b. orienting the family to the ICU visitation policy. c. making sure that the consent forms are signed. d. informing the patient of his HIPAA rights. When a critically ill patient reaches a hospital’s nursing division, the patient immediately undergoes extensive examination and treatment procedures. Little time is available for the nurse to orient the patient and family to the division, or to learn of their fears or concerns. DIF: CognitiveLevel: Analysis OB): Describe the nurse's role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: Role of the Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity . The nurse is admitting the patient to the medical unit. The patient indicates that he has had several surgeries in the past and has been a diabetic for the past 15 years. He also stated that he is allergic to Morphine. What does this information prompt the nurse to do next? a. Provide the patient with an allergy armband and document his allergies. b. Postpone routine admission procedures immediately. c. Ask the patient if he wants a smoking room. d. Have all family or friends leave the room. di. 12. c. Escorting the patient to the transport area d. Assessing the patient‘s respiratory status before transport ANSWER: D The assessment and decision making conducted during transfers cannot be delegated to nursing assistive personnel. NAP can assist the patient with dressing, can gather and secure the patient‘s personal belongings and any necessary equipment, and can escort the patient to the nursing unit or transport area. DIF: CognitiveLevel: Application OB): Describe the nurse’s role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment When does the plan for patient discharge from a health care facility begin? a. At admission b. After a medical diagnosis has been determined a When the patient‘s physical needs are identified d. After a home environment assessment is completed Planning for discharge begins at admission and continues throughout the patient's stay in the agency. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous. DIF: CognitiveLevel: Comprehension OB): Describe the nurse’s role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment The phase of the DischargeProcess where medical attention dominates discharge planning efforts is known as the phase. a. transitional 13; b. continuing c. acute d. multidisciplinary ANSWER: C The DischargeProcess occurs in three phases: acute, transitional, and continuing care. In the acute phase, medical attention dominates discharge planning efforts. During the transitional phase, the need for acute care is still present, but its urgency declines and patients begin to address and plan for their future health care needs. In the continuing care phase, patients participate in planning and implementing continuing care activities needed after discharge. There is no multidisciplinary stage; the discharge planning process is comprehensive and multidisciplinary. DIF: CognitiveLevel: Comprehension OB): Describe the nurse's role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Once a patient’s discharge has been completed, which activity may be delegated to assistive personnel? a. Provision of prescriptions to the patient b. Completion of the discharge summary ° Gathering of the patient‘s personal care items d. Provision of instructions on community health resources ANSWER: C The assessment, care planning, and instruction included in discharging patients cannot be delegated to nursing assistive personnel. The nurse may direct the NAP to gather and secure the patient's personal items and any supplies that accompany the patient. DIF: CognitiveLevel: Application OB): Describe the nurse’s role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation 14. 15: MSC: NCLEX: Safe and Effective Care Environment The nurse is providing discharge instruction to an 80-year-old patient and her daughter. The patient lives in a two-story home. When asked if the patient has difficulty climbing stairs, the patient says —No,| but the nurse notices a look of surprise on the daughter's face. What should the nurse do in this circumstance? a. Speak with the daughter separately. b. Cancel the discharge immediately. a Order a visiting nurse consult. d. Notify the physician. Patients and family members often disagree on the health care needs of a patient after discharge. Identifying these discrepancies early leads to more accurate development of the discharge plan. It is often necessary to talk with the patient and family separately to learn about their true concerns or doubts. DIF: CognitiveLevel: Application OB): Explain the role of the patient's family in the admission, transfer, or DischargeProcess. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment The patient has decided that he would like to create an advance directive. The nurse is asked if she would be a witness. What is the best response for the nurse to make to this request? a. Agree to be a witness. b. Refuse to be a witness. Contact social work. a d. Contact the physician. ANSWER: /C A social worker often fulfills this requirement. Witnesses for an advance directive document should not be medical personnel, and direct refusal does not meet the nurse's obligation to meet the patient's needs. Referral to a department that can ensure this service is required. DIF: CognitiveLevel: Application 4. Which of the following are considered —advance directivesi? (Select all that apply.) Living will o 2 Power of attorney for health care Notarized handwritten document a d. Nursing progress note ANSWERHA, B, C Advance directives may include a living will, power of attorney for health care, or a notarized handwritten document. DIF: CognitiveLevel: Analysis OB): Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment . The patient is being transferred from the intensive care unit to the acute care unit. The nurse must ensure that the following activities are completed: (Select all that apply.) a. providing the receiving nurse with a report before the transfer. b. determining any equipment needs for the patient during the transfer. c. providing an updated report after transferring the patient to the receiving unit. d. making sure a registered nurse accompanies the patient. ANSWERHA, B, C When providing a —hand-offl of a patient to another unit, it is essential that information about the patient’s care, treatment, services, and current condition and any recent or anticipated changes are communicated accurately to meet patient safety goals. The nurse first provides a telephone report to the receiving nurse. This allows the receiving nurse to prepare for the patient (e.g., preparing the room, securing necessary equipment). As clinically appropriate, a nurse or technician accompanies the patient during transport, providing the receiving nurse with the patient's medical record; introducing the patient to the receiving nurse; and providing an updated report, including any changes in clinical status or plan of care. DIF: CognitiveLevel: Application OB): Describe the nurse’s role in maintaining continuity of care through a patient's admission, transfer, and discharge from an acute care facility. TOP: Continuum of Care KEY: NursingProcess Step: Implementation advance directive An advance directive is a document that provides a patient’s instructions about future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity. An advance directive conveys the patient's choice in continuing medical care when the patient is unable to speak or make decisions. DIF: CognitiveLevel: Knowledge OB): Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: NursingProcess Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment Chapter 04: Documentation and Informatics Perry et al.: Clinical Nursing Skills & Techniques, 11th Edition a MULTIPLE CHOICE 1. The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information? a. The patient's parents b. The patient's significant other only No one in the hospital until the patient says so a d. The patient's physician, significant other, and laboratory personnel ANSWER: D All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient's examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient. DIF: CognitiveLevel: Application OB): Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is the best example of objective charting? a. —The patient states that he has been having severe chest discomfort. b. —The patient is lying in bed and seems to be in considerable pain.| c. —The patient appears to be pale and diaphoretic and complains of nausea.| d. —The patient's skin is ashen and respiratory rate is 32 and labored.| ANSWER: D A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as —respiratory rate 20 and unlabored.| Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient's exact words whenever possible. For example, you record, —Patient states, _my stomach hurts.‘l Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description —the patient seems to be in painl does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts. DIF: CognitiveLevel: Analysis OB): List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity 3. Which of the following is the best example of accurate documentation? a. —Abdominal wound is 5 cm in length without redness, edema, or drainage. b. —OD to be irrigated qd with NS.I c. —No complaint of abdominal pain this shift. d. —Patient watching TV entire shift.| DIF: CognitiveLevel: Analysis OB): Identify the purpose of the patient record. TOP: Acuity Records KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment . A guideline used to care for patients with similar health problems is known as the: a. acuity record. b. standardized care plan. a patient care summary. d. flow sheet. ANSWER: B Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution‘s standards of nursing practice, are preprinted, established guidelines that are used in caring for patients with similar health problems. Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: CognitiveLevel: Analysis OB): Identify the purpose of the patient record. TOP: Standardized Care Plans KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment . The patient is ready to go home from the hospital. What does the nurse provide to the patient and his family before he leaves the facility? a. Discharge summary b. Standardized care plan c. Patient care summary d. Flow sheet When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient's ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: CognitiveLevel: Application OBJ: Identify the purpose of the patient record. TOP: Discharge Summary Forms KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment . The patient has been in the hospital for a hip replacement. According to his critical pathway, he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of: a. a negative variance. b. positive case management. c. a positive variance. d. use of SBAR. ANSWER: C Document in the patient‘s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk-management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent. DIF: CognitiveLevel: Analysis OBJ: Complete an incident report accurately. TOP: Incident Reports KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Nursing documentation: (Select all that apply.) a. ensures continuity of care. b. provides legal evidence. a evaluates patient outcomes. d. increases the risk of litigation. ANSWEREHA, B, C Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes. Effective documentation ensures continuity of care, maintains standards, and reduces errors. DIF: CognitiveLevel: Knowledge OB): List guidelines for effective communication and reporting. TOP: Communication KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. Nursing documentation must have which of the following characteristics? (Select all that apply.) a. Factual b. Organized Public a d. Complete ANSWERIA, B, D Quality documentation and reporting have six characteristics: they are factual, accurate, complete, current, organized, and confidential. DIF: CognitiveLevel: Comprehension OB): List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. A patient‘s private health information is legally protected by the___. ANS: Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act HIPAA HIPAA protects patients‘ private health information. This governs all areas of health information management, including, for example, reimbursement, coding, security, and patient records. DIF: CognitiveLevel: Application OB): Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. documentation should include your observations of patient behavior. ANS: Objective Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. DIF: CognitiveLevel: Analysis OB): List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: NursingProcess Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment . The abbreviation for every day ( ) is no longer used. ANS: qd The abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word —dailyl or —every dayl on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). DIF: CognitiveLevel: Application OB): List guidelines for effective communication and reporting. TOP: Accurate Documentation KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment . When making written entries in the patient‘s medical record, describe the nursing care provided and the. ANS: patient’s response The information within a recorded entry or a report must be complete, containing appropriate and essential information. Make written entries in the patient’s medical record, describing nursing care that you administer and the patient‘s response. DIF: CognitiveLevel: Application MSC: NCLEX: Physiological Integrity . A person‘s core temperature is considered the most accurate since it is: a. reflective of the surrounding environment. b. the same for everyone. a controlled by the hypothalamus. 2 independent of external influences. ANSWER: C The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37° C (98.6° F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health. DIF: CognitiveLevel: Analysis OB): Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Core Temperature KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity . The nurse takes the patient's temperature using a tympanic electronic thermometer. The temperature reading is 36.5° C (97.7° F). The nurse knows that this correlates with: a. 37.0° C (98.6° F) rectally. b. 37.0° C (98.6° F) orally. c. 36.0° C (97.7° F) axillary. d. 36.0° C (97.7° F) orally. ANSWER: B It generally is accepted that axillary and tympanic temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. It generally is accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures. DIF: CognitiveLevel: Analysis OB): Discuss factors involved in selecting temperature measurement sites. TOP: Temperature Assessment KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity . The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his —cigarette break. The nurse is about to take the patient‘s temperature orally and should: a. wait about 20 minutes before taking his temperature. b. give him oral fluids to rinse the nicotine away before taking his temperature. c. give him a stick of chewing gum to chew and then take his temperature. d. take his oral temperature and record the findings. The nurse should verify that the patient has not had anything to eat or drink and has not chewed gum or smoked within the 15 minutes before oral temperature is measured. Oral food and fluids and smoking and gum can alter temperature measurement. DIF: CognitiveLevel: Synthesis OB): Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Oral Temperature Assessment KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity . When evaluating the patient's temperature levels, the nurse expects the patient’s temperature to be lower: a. in the morning. b. after exercising. c. during periods of stress. d. during the postoperative period. Temperature is lowest during early morning. Muscle activity and stress raise heat production. Drugs may impair or promote sweating, vasoconstriction, or vasodilation, or may interfere with the ability of the hypothalamus to regulate temperature.