chapter 15

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Resumen del Recurso

Pregunta 1

Pregunta
Which action by a nurse ensures confidentiality of a client’s computer record?
Respuesta
  • The nurse logs on to the client’s file and leaves the computer to answer the client’s call light.
  • The nurse shares her computer password.
  • The nurse closes a client’s computer file and logs off.
  • The nurse leaves client computer worksheets at the computer workstation.

Pregunta 2

Pregunta
The case management model using critical pathways would be appropriate for a client with which diagnosis?
Respuesta
  • Myocardial infarction (heart attack)
  • Diabetes, hypertension
  • Myocardial infarction, diabetes, hypertension
  • Diabetes, hypertension, an infected foot ulcer, senile dementia

Pregunta 3

Pregunta
After making a documentation error, which action should the nurse take?
Respuesta
  • Use correcting liquid to cover the mistake and make a new entry.
  • Draw a line through it and write error above the entry.
  • Draw a line through it and write mistaken entry above it.
  • Draw a line through the mistake and write mistaken entry with initials above it.

Pregunta 4

Pregunta
Which charting entry would be the most defensible in court?
Respuesta
  • Client fell out of bed
  • Client drunk on admission
  • Large bruise on left thigh
  • Notified Dr. Jones of BP of 90/40

Pregunta 5

Pregunta
The client’s VS are WNL. He has BRP and he receives his pain pill PRN. His nutrition is DAT. Interpret the commonly used abbreviations. (write interpretations on paper, default answer will be a, answer will be given at the end of test)
Respuesta
  • NKA:___________
  • BRP:___________
  • PRN:___________
  • DAT:__________

Pregunta 6

Pregunta
During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client’s blood pressure (BP) seems high. What is the next step?
Respuesta
  • Ask the client about past blood pressure ranges.
  • Review the graphic record on the client’s record.
  • Examine the medication record for antihypertensive medications.
  • Review the progress notes included in the client’s record.

Pregunta 7

Pregunta
A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse represents effective nursing practice? Select all that apply
Respuesta
  • Provides the medical diagnosis or reason for admission
  • States the time the client last received pain medication
  • Speaks loudly when giving report
  • States priorities of care that are due shortly after the report
  • Reports on number of visitors for each client

Pregunta 8

Pregunta
Which charting entries are written correctly? Select all that apply.
Respuesta
  • MS 5 gr given IV for c/o abdominal pain
  • Lanoxin 0.25 mg given orally per Dr. Smith’s stat order
  • KCl 15 mL given orally for K+ level of 2.9
  • Regular insulin 10.0 u given SQ for capillary blood glucose of 180
  • Ambien 5 mg given orally at bedtime per request

Pregunta 9

Pregunta
A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes whatappears to be cigarette burns on the client’s inner thighs. Which of the following is the most appropriate documentation?
Respuesta
  • Six round skin lesions partially healed, on the inner thighs bilaterally
  • Several burned areas on both of the client’s inner thighs
  • Multiple lesions on inner thighs possibly related to elder abuse
  • Several lesions on inner thighs similar to cigarette burns

Pregunta 10

Pregunta
Which charting rule(s) will keep the nurse legally safe? Select all that apply.
Respuesta
  • Use military time
  • Document worries or concerns expressed by the client.
  • Perform most of the charting at the end of the shift.
  • Record only information that pertains to the client’s health problems.
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