The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following?

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change?

A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation?

The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?

For the patient with no healthcare coverage who is seeking medical care, the emergency department staff members decide whether to provide care or transport to a public facility based on which law, enacted by Congress in 1986 and updated in 2003?

In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient?

You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, “I’m leaving this hospital. Remove my IV and surgical drains or I will do it myself.” In order to keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following?

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. Of the following choices, which would be the most important thing to look up in the chart first?

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall.

The nursing Rand card or Kardex® is part of the patient’s permanent health record.

Which set of topics makes up a hand-off report given in a recommended format?

The nurse makes a mistake while documenting in the patient’s health record. Which action should the nurse take?

The patient’s medical record contains the following documentation:
06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN
Which type of charting has the nurse used?

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 client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication?

Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient’s arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws?

The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse to document on the MAR?

A patient refuses a dose of medication. How should the nurse document the event?

A 4-year-old child is brought to the emergency department by his mother. He has a large bruise in his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four items should the nurse do first?

A patient tells you that chart entries made by the nurse from the previous day indicate he was uncooperative when asked to ambulate. He says this is not true and asks his record be corrected. You understand that, if what he says is accurate, he has the right to have the documentation error corrected based on which of the following regulations?