MISC
A nurse is assessing his patients in the morning and finds that a frail a 85 year-old female patient is soiled in bed. The patient reports that she has been asked to cleaned numerous times and has been ignored. Of the following, which demonstrates appropriate documentation in the patient's chart.
A. The patient was found soiled in bed by this RN. she reports being left alone all night by the night shift RN, who did not clean her before the change of shift. She was given a bed bath and provided skin care. Her skin was reddened on her buttocks; emollient applied.
B. The patient was found soiled in bed by this RN. She was incontinent of urine and feces and she said she was "ignored for hours" by the night shift RN. She was given a bed bath and provided skin care. Her skin was reddened on her buttocks; emollient applied.
C.The patient was found soiled; incontinent of urine and feces. She was given a bed bath and provided skin care. Her skin was reddened on the buttocks; Emollient applied. Incident report made.
D. The patient was found soiled; incontinent of urine and feces. She was given a bed bath and provided skin care. Her skin was reddened on the buttocks; emollient applied.
D. The patient was found soiled; incontinent of urine and feces. She was given a bed bath and provided skin care. Her skin was reddened on the buttocks; emollient applied.
**Documentation Must stick to objective descriptions of what happen in any assessments and interventions performed. Personal biases or information that applies misconduct should never be documented in the patient's chart
Which vitamins are fat soluble (Select all that apply)
A
B
C
D
E
K
Vitamins A D E K
See your chapters on Nutrition (what does it mean to be fat soluble and water soluble
What are Vitamin B & C
A client who is recovering from a surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been bored with the clear liquid diet. The nurse should offer which full liquid item to the client?
1. Tea
2. Gelatin
3. Custard
4. Ice pop
Nursing research is based on the _________________ method.
1) Qualitative
2) Scientific
3) Self-transcendence
4) Mechanical
2) Scientific
See your book regarding nursing process this word is in bold print.
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply
1. Broth
2. Coffee
3. Gelatin
4. Pudding
5. Vegetable juice
6. Pureed vegetables
1,2,3
Clear liquid is just that clear can you see through it
The others options would be on a full-liquid diet
A nurse is documenting on a client who had an unwitnessed fall, The nurse documents the following in the chart: patient fell on bathroom floor at 1715. Patient reported that she "lost her balance" while toileting. Vital signs were WNL (within normal limits) and BP 115/87. Patient has a bruise on her right thigh and reports 4/10 pain at the thigh. No obvious deformity, CMS normal. POA and MD informed; pt put on fall precautions. Tylenol 650 mg by mouth given at 1740 hrs. Pain 1/10 at 1830 hrs.
Of the following, which is an example of inappropriate documentation of this incident?
A. POA and MD inform; pt put on fall precautions
B. Patient has a bruise on her right thigh reports 4/10 pain at the thigh. Tylenol 650 mg PO Given at 1740 hrs. Paid 1/10 at 1830 hrs.
C. Patient reported that she "lost her balance "while toileting
D. Patient fell on the bathroom floor at 1715 hrs.
D. Patient fell on the bathroom floor at 1715 hrs.
Documentation should include where the patient was found and who found them and any objective observations only. It should be noted if they were on precautions of any kind. Never document that the patient fell unless someone actually witnessed the fall
The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which items from her menu?
1. Nuts and ilk
2. Coffee and tea
3. Cooked rolled oats and fish
4. Oranges and dark green leafy vegetables
4.
Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption
What type of interview technique is the nurse using when the nurse asks the question, "Do you have pain or cramping?"
A) Active listening
B) Open-ended questioning
C) Closed-ended questioning
D) Problem-oriented questioning
C. Closed-ended question
The example is a closed-ended question which the client can answer with a one-word reply. Open-ended questions allow the client to answer with more information. The other options are not correct.
When caring for a patient with a cardiac dysrhythmia, which laboratory value is a priority for the healthcare provider to monitor?
a. BUN and creatinine
b. Sodium, potassium, and calcium
c. Hemoglobin and hematocrit
d. PT and INR
b. Sodium, potassium, and calcium
(Fluids and Electrolytes practice for Exam 4)
- BUN and creatinine levels are always important to monitor when giving any drug, not only antidysrhythmia drugs.
- The PT and INR will be important for patients who are on warfarin (Coumadin).
- Because abnormalities in sodium, potassium and calcium levels are likely to affect depolarization and repolarization of cardiac cells, it is most important for the healthcare provider to monitor these laboratory values.
The nurse is giving discharge instuctions to a newly diagnosed diabetic patient. Which of the following foods should she include when teaching about foods containing 15 grams of carbohydrates per serving?
a. Pickles and Olives
b. Peanut Butter and Celery
c. Bread and Crackers
d. Turkey and Cheese
c. Bread and Crackers
theses are carbohydrates what happen when digested (turns into sugar, see the Nutrition chapters)
Which of the following should the nurse delegate to the LPN.
Select all that apply:
A. Administering a piggyback IV medication
B. IM medication administration
C. Initiating a primary IV medication
D. Oral medication administration
E. Urinary catheterization
A, B, D, E
Initiating a primary IV medication must be done by an RN
All other options are within the LPN scope of practice
Which of the following is the most important reason for nurses to be critical thinkers?
1) Nurses need to follow policies and procedures
2) Nurses work with other healthcare professionals
3) Nurses care for patients with multiple health issues
4) Nurses have to be flexible and work different schedules
3) Nurses care for patients with multiple health issues
Nurses use critical thinking to care for them.
Which of the following is an example of an active listening behavior?
1) Taking frequent notes
2) Asking for more details
3) Leaning in, facing the patient
4) Sitting with legs crossed
3) Leaning in, facing the patient
A patient who moved to the US from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet still retains some customs from her homeland. This patient is experiencing:
1) assimilation
2) socialization
3) enculturation
4) immigration
3
See Chp 14
In performing a hand-off report, the nurse should communicate information on: (select all that apply)
1) Teaching performed
2) Any change in client status
3) Treatments administered
4) Hygiene measures performed
1,2,3
Hygiene is important but not the focus of bedside hand-off report. Bedside hand-off/report gives the important information to allow the nurse taking over to priorities. review Chapter 8 when giving clear too the point bedside report/handoff
Which of the following tasks can be delegated to a nursing assistant?
Select all that apply.
A. Ambulating a stable patient
B. Emptying and measuring a foley catheter reservoir
C. Intake and output documentation
D. Irrigating a nasogastric tube
E. nasotracheal suctioning of a stable patient
F. Setting up patient controlled analgesia
A, B, C
The nurse can safely delegate the ambulation of the stablenpatient, I&O documentation, and emptying and measuring urine from the Foley to the nursing assistant.
All other options cannot be safely delegated to the nursing assistant
A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of:
A. Planning
B. Evaluation
C. Assessment
D. Intervention
C. Assessment
Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is analyzed for problem resolution. Intervention consists of the steps actually taken after planning. Evaluation measures the effectiveness of the plan.
What techniques encourage a client to tell his or her full story? (Select all that apply.)
A) Active listening
B) Back channeling
C) Use of open-ended questions
D) Use of closed-ended questions
A, B, and C
Options 1, 2, and 3 encourage clients to tell their full stories. Closed-ended questions allow clients to answer with one or two words, which makes it more difficult to obtain all the information required for a full story. The other options give clients the opportunity to tell their stories and feel supported. Active listening helps them feel that they, and their stories, are important.
A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data?
(Select all that apply.)
A) Pain intensity
B) Location of pain
C) Character of pain
D) Radiation of pain
E) Meaning of pain to the client
F) Family history of myocardial infarctions
A, B, C, D, and E
The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation.
Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse should not:
A) Include subjective data from the client.
B) Perform a thorough physical examination.
C) Use interpersonal and cognitive skills.
D) Include inferences or interpretative statements not supported with data.
D. Include inferences or interpretative statements not supported with data
The nurse should not generalize or form judgments not supported by the collected data. Inferences and interpretive statements must be supported by data. Assessments do include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client.
Which of the following best illustrates evaluation step of the nursing process?
after
A. Ask the patient if there is anything else we need before you leave the room
B. Assessment of lung sounds on the new admission
C. Auscultating and palpating a patient's abdomen when he complains of new Abdominal pain
D. Reassessment of pain after pain medication is administered
D. the evaluation phase of the nursing process involves measuring the effectiveness of the interventions implemented in the plan of care including reassessing pain after medication
A client with diabetes mellitus who takes daily insulin injections is scheduled for surgery the next day. The client is to take nothing by mouth (NPO status) after midnight. The nurse questions whether insulin should be given the morning of surgery. This is an example of:
A) Problem solving
B) Previous experience
C) Clinical practice guideline
D) Scientifically based clinical judgment
D. Scientifially based clinical judgment
See Nursing process chapters, and Nutrition chapters
The nurse is demonstrating awareness of the effect of insulin, which is to lower blood glucose level. Because the client will be NPO status for a long period of time, no calories will be consumed. Giving the usual injection of insulin could cause the client to experience hypoglycemia.
Which of the following is the most accurate information to give a nurse during change-of-shift reporting?
A) Client refuses to take medications.
B) Client reports sharp pain in left anterior knee.
C) Client encouraged to consume more fluids.
D) Client expressed concern about pending surgery.
B. Client reports sharp pain in elft anterior knee
The information in option 2 represents objective data that the nurse can use as part of baseline information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact concern would be more accurate. Option 1 may be true, but accurate data would also report why the client refused medication.
The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the med-surg floor. Which of the following patients can the nurse delegate to the NAP the task of bathing? Select all that apply.
1) 75 year old patient newly admitted with dehydration
2) 65 year old patient hospitalized for a stroke whose BP is 189/90
3) 92 year old patient with stable vital signs who was admitted with a UTI
4) 56 year old patient with chronic renal failure who has Vital signs within his normal range.
1,3,4
A 65 year old who suffered a stroke and has high BP would not be appropriate for the CNA to bathe themselves. This client is not stable
In the examples given below, which nurse is acting to avoid a data collection error?
A) The nurse asks her colleague to chart her assessment data.
B) The nurse considers conflicting cues in deciding on the correct nursing diagnosis.
C) The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her.
D) After performing an assessment the nurse critically reviews his level of comfort and competence with interviewing and physical assessment skills.
C.
The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her.
A nurse who is uncertain and asks a colleague to consult is avoiding a data collection error. The nurse reviewing his level of comfort and competence is being complete but can miss his own errors. Considering conflicting clues does not help avoid data collection errors. Asking a colleague to chart data is incorrect.