Documentation
True or False: “Patient seems upset” is objective data.
What is False? : Objective data consists of factual, measurable, or observable information, while subjective data is based on personal interpretations and feelings.
What is the first step of the nursing process?
What is assessment?
Normal adult respiratory rate is?
What is 12–20 breaths per minute?
What is the most effective way to prevent infection?
What is proper hand hygiene (handwashing or using alcohol-based hand rubs)?
What is the first step when a fire alarm sounds on the unit?
What is evacuate or move patients to a safe location according to the fire plan?
Why is “charting by exception” used?
What are efficiency & time-saving, clarity & focus, consistency in documentation, legal protection, and cost-effectiveness?
Give an example of subjective data.
What is, “I feel dizzy”
Where is the apical pulse located?
What is the fifth intercostal space at the left midclavicular line (over the apex of the heart)?
Which type of isolation is required for TB?
What is airborne isolation?
Name the acronym for using a fire extinguisher.
What is PASS?
Give an example of proper late entry documentation.
What are: label it clearly as “Late Entry,” include the original event time, document as soon as possible, remain objective, and sign with credentials?
Why must nursing diagnoses focus on patient responses instead of medical diagnoses?
What is, Nursing diagnoses must focus on this, rather than medical conditions, because they guide nursing-specific interventions.
A patient’s BP is 88/50. What should the nurse do first?
What is assess the patient for symptoms of hypotension (e.g., dizziness, altered LOC) before notifying the provider?
True or False: Alcohol-based hand rubs kill C. difficile spores.
What is False?
A patient is a fall risk. List two safety interventions.
What is, placing a patient’s bed in the lowest position, keeping the call light within reach, avoid throw rugs, and wear proper non-skid shoes?
Which abbreviation is NOT allowed: QD, BID, TID?
What is QD?
A patient states, “I have sharp stomach pain.” What part of the nursing process is this?
What is assessment?
Name two factors that can increase blood pressure.
What is, Stress, pain, obesity, smoking, or excess sodium intake are examples of factors that can do this to blood pressure.
Name three PPE items needed for droplet precautions.
What is, Gloves, gown, and surgical/face mask?
What device helps lift a patient from bed to chair safely?
What is a mechanical lift (or Hoyer lift)?
Why must documentation be clear, concise, and timely?
What is to ensure patient safety, provide legal protection, support professional communication, demonstrate accountability, and allow for accurate billing?
Which step of the nursing process involves setting measurable goals?
What is planning?
A rectal temperature reads 102.6°F. What is this called?
What is a fever (or hyperthermia)?
Define medical vs. surgical asepsis.
What is, medical asepsis involves practices that reduce the number of pathogens? While surgical asepsis involves practices that keep an area or object completely free of all microorganisms.
What side of the body should a patient with weakness use a cane on?
What is the stronger (unaffected) side?