Nursing Process
What type of data is a patients statement of "I feel dizzy"?
Subjective Data
A nurse walks into a patients room and finds them short of breath with an o2 sat of 86% on room air. Which of the following best represents the "Situation" part of SBAR.
A- Pt is post op day 2 from an abdominal surgery and has a history of COPD.
B- Pt is complaining of shortness of breath and has a 02 sat of 86%
C- i recommend a stat respiratory therapy consult and an order for a chest x-ray.
D- Patient's lung sounds are diminished bilaterally
B- pt is complaining of SOB and has an o2 sat of 86%
Which of the following is an example of medical asepsis?
A- sterilizing surgical instruments
B- performing a surgical hand scrub
C- washing hands before eating
D- donning sterile gloves for catheter insertion
C- washing hands before eating
Which of the following is an example of a primary skin lesion?
A- ulcer
B- scar
C- papule
D- Fissure
C- papule
which of the following is the most appropriate documentation?
A- pt seems mad
B- Pt is difficult and uncooperative
C- Pt stated, 'I'm upset about the delay in care'
D- Pt is lying and exaggerating pain
C- Pt stated, 'I'm upset about the delay in care'
What is the correct format for writing a nursing diagnosis?
[Problem] related to [cause] as evidenced by [signs/symptoms]
What information should be included in the background of an SBAR communication?
A- the patients diet order and insurance type
B- current assessment findings
C- code status, relevant history, and recent procedures
D- what the nurse reccomends for next steps
C- code status, relevant history, and recent procedures
when should a nurse perform hand hygiene?
A- before pt contact
B- after removing gloves
C- before eating lunch
D- after touching medical equipment
E- after using the restroom
F- all of the above
F- all of the above
A nurse notes a flat, non-palpable, brown spot on a pt's forearm. Which lesion is this?
A- macule
B- vesicle
C- papule
D- pustule
A- macule
When should documentation be completed?
A- at the end of the nurses shift
B- before administering medications
C- as soon as possible after care is given
D- the next day if too busy
C- as soon as possible after care is given
What is the goal of the planning step?
To set measurable, patient-centered goals and choose appropriate nursing interventions
A nurse notes a pt has a fever of 101.9, heart rate of 115, and foul smelling urine. Which statement best fits the "Assessment" in SBAR?
A- pt has a history of urinary tract infections
B- I think the pt may have developed a UTI
C- Pt is on abx for pneumonia
D- can you prescribe a urine culture?
B- I think the patient may have developed a UTI
what is the most effective way to prevent the spread of infection in healthcare settings?
A- wearing gloves
B- disinfecting surfaces
C- hand hygiene
D- isolating all patients
C- hand hygiene
a vesicle is best described as:
A- a solid elevated lesion >1cm
B- a fluid filled lesion <1cm
C- a thickened, roughened area of the skin
D- a crusted, dried blood lesion
B- a fluid filled lesion <1cm
Which documentation entry is legally appropriate?
A- "Accidentally gave wrong dose, but no harm done"
B- "Gave med without MD order- oops"
C- "Notified provider; new order received and implemented."
D- "Didnt follow protocol because pt was too needy"
C- "Notified provider; new order received and implemented."
Give an example of a SMART goal
specific
measurable
attainable
realistic
time
Which of the following is the best example of the recommendation step in SBAR?
A- I think the pt may have an infection based on the symptoms
B- the pt is alert and oriented but reports chills
C- i recommend ordering a urine culture and starting empiric abx
D- the pt is allergic to sulfa drugs
C- I recommend ordering a urine culture and starting empiric abx
A nurse is setting up a sterile field. Which action breaks sterile technique?
A- touching the outer 1-inch edge of the sterile drape
B- holding sterie objects above waist level
C- turning your back to the sterile field
D- opening the sterile package away from your body first
C- turning your back to the sterile field
Which of the following would be considered a secondary lesion?
A- wheal
B- nodule
C- crust
D- bulla
C- crust
Which action is correct if a nurse makes a documentation error?
A- erase the mistake and rewrite it
B- use white out to correct it
C- draw a single line through the error , write "error", and initial it
D- remove the page and start over
C- draw a single line through the error , write "error", and initial it
what is the difference between a medical diagnosis and a nursing diagnosis?
medical diagnosis identifies a disease, while a nursing diagnosis focuses on pt responses
A nurse is calling a provider about a pt with chest pain. Using SBAR what should be included in the situation part?
A- mr. johnson is a 68 year old with a hx of HTN and high cholesterol.
B- His VS are: BP 140/90 HR 110 RR 22 Temp 98.6
C- This is nurse smith calling about Mr. Johnson in room 204. He is experiencing chest pain rated 8 out of 10 that started 10 minutes ago.
D- I think we should order an EKG and give nitroglycerin per standing orders.
C- This is nurse smith calling about Mr. Johnson in room 204. He is experiencing chest pain rated 8 out of 10 that started 10 minutes ago.
Which situation requires surgical asepsis instead of medical asepsis?
A- administering an injection
B- removing soiled linens
C- inserting a foley catheter
D- feeding a patient
C- inserting a Foley catheter
What type of skin lesion is commonly seen in contact dermatitis or hives?
A- plaque
B- wheal
C- ulcer
D- fissure
B- wheal
what is the primary purpose of accurate documentation in nursing?
A- to protect the nurse from lawsuits
B- to provide legal proof of care
C- to ensure continuity and quality of care
D- to comply with hospital rules
C- to ensure continuity and quality of care.