DeWit’s Fundamental Concepts and Skills for Nursing, 5th Edition By Patricia A. Williams -Test Bank A+

Description

1. The nurse is aware that one of the time flexible tasks to be accomplished would be:

a.	administering daily insulin 30 minutes before breakfast.
b.	taking the patient’s vital signs once a day.
c.	weighing the patient before breakfast.
d.	monitoring a critical patient’s vital signs every 15 minutes.

ANS: B

Daily vital signs can be taken at any time during the day, whereas the other tasks mentioned have a time constraint.

DIF: Cognitive Level: Application REF: p. 73 OBJ: Theory #2

TOP: Care Delivery KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially:

a.	question the rationale for the procedure.
b.	perform a physical assessment of the patient.
c.	check the agency manual for the procedure.
d.	mentally review the procedure.

ANS: D

Reviewing the procedure, checking the manual if uncertain, confirming the order for the procedure, assessing that there is no interference with the completion of the procedure, and identifying the patient are standard steps in deliberative nursing action.

DIF: Cognitive Level: Application REF: p. 76|Box 6-2

OBJ: Theory #1 TOP: Care Delivery

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. At the 7:00 AM handoff report, the nurse receives the report that patient A had a sleepless night related to pain and just fell asleep after an increased pain medication administration 1/2 hour ago. Patient B, who is scheduled for surgery at 8:30 AM, is also sleeping. How would an organized nurse plan the early morning activities?

a.	Wake patient A for breakfast.
b.	Perform time flexible tasks that can be done while both patients sleep.
c.	Prepare patient B now; allow patient A to sleep.
d.	Assign a nursing assistant to wake and help feed patient A.

ANS: C

Setting priorities and identifying time fixed tasks would indicate that patient B needs to be prepared for surgery. Patient A needs to sleep.

DIF: Cognitive Level: Analysis REF: p. 73 OBJ: Theory #1

TOP: Care Delivery KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. Preparing a patient for a diagnostic test, and telling the patient what to expect during and after the test, is considered:

a.	an independent nursing action.
b.	the doctor’s responsibility.
c.	a dependent nursing action that requires the doctor’s authorization.
d.	an interdependent nursing action.

ANS: A

Patient education is an independent nursing action.

DIF: Cognitive Level: Comprehension REF: p. 74 OBJ: Theory #2

TOP: Patient Education KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The nurse explains that a multidisciplinary step-by-step approach to patient care is:

a.	documented in the nursing care plan in the patient’s medical record.
b.	not used often since managed care became part of health care.
c.	referred to as a clinical pathway and is used instead of a nursing care plan.
d.	more expensive than the traditional separation of health care services.

ANS: C

An outgrowth of managed care has been collaborative models of care called clinical pathways.

DIF: Cognitive Level: Knowledge REF: p. 74 OBJ: Theory #1

TOP: Clinical Pathways KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. The nurse documents interventions periodically during the shift in nurses’ notes primarily to:

a.	validate the number of nonlicensed personnel who interact with the patient.
b.	indicate that the nursing care plan has been implemented.
c.	briefly summarize activities during the shift.
d.	confirm that the nursing diagnoses in the care plan are appropriate.

ANS: B

The nursing care must be documented in the nurses’ notes to prove that interventions were implemented. In some facilities documentation is required at least every 2 hours.

DIF: Cognitive Level: Comprehension REF: p. 76 OBJ: Theory #3

TOP: Documentation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. The nurse compares actual nursing outcomes to the expected nursing outcomes in order to:

a.	prepare the patient to be discharged from the facility.
b.	determine if the patient’s health problems have been treated.
c.	calculate charges for nursing services during the patient’s hospital stay.
d.	determine if progress is made or to determine if revisions are needed.

ANS: D

Evaluation of patient responses to treatment and progress toward goals is performed continuously so that the nursing care plan may be modified if needed.

DIF: Cognitive Level: Comprehension REF: p. 77 OBJ: Theory #5

TOP: Outcomes KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The general rule is that the initial care plan for a patient is:

a.	developed by an RN in an acute care setting.
b.	used as the basis of care throughout a hospital stay without alteration.
c.	completed on the day of admission.
d.	developed by the primary care provider and incorporated into the nursing care.

ANS: A

An RN is responsible for developing the plan of care for patients in acute care settings. An LPN may begin the care plan in a skilled nursing facility and will collaborate with the RN for revision. The nursing care plan will be revised frequently as the patient’s condition changes.

DIF: Cognitive Level: Comprehension REF: p. 79 OBJ: Theory #2

TOP: Care Planning KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. The nurse is aware that the nursing audit is a valuable process used to:

a.	determine whether a particular patient received the care indicated in the nursing care plan.
b.	evaluate whether nursing care for a group of patients meets the standards of care in that facility.
c.	determine the cost of nursing care in the hospital in order to set rates for daily care.
d.	identify careless or negligent nursing care to protect the facility from lawsuits.

ANS: B

Nursing audits are performed to improve nursing practice by checking a group of patient records for how well particular standards were met and standards of care were being used.

DIF: Cognitive Level: Knowledge REF: p. 79 OBJ: Theory #6

TOP: Nursing Audits KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. The nurse evaluates that the patient has met the outcome of feeding himself independently. The nurse should:

a.	inactivate the nursing diagnosis from the care plan.
b.	notify the primary care provider that the patient can now feed himself.
c.	document the ability to self-feed and mark the nursing diagnosis as resolved.
d.	inform the RN to document the self-feeding and to cancel the nursing diagnosis.

ANS: C

The LPN should document the meeting of the outcome and mark the nursing diagnosis as “resolved.”

DIF: Cognitive Level: Application REF: p. 77 OBJ: Theory #6

TOP: Nursing Care Plan Revision KEY: Nursing Process Step: Intervention

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. An example of an appropriately worded nursing goal or outcome for the nursing diagnosis of “Risk for falls related to weakness” would be:

a.	nurse will assist the patient to the bathroom every 2 hours.
b.	patient will be free of injury from falls.
c.	patient will call for assistance when ambulating for the next week.
d.	nurse will keep room well lit 24 hours a day.

ANS: C

An appropriately worded outcome is a patient centered, measurable, and time defined goal based on a nursing diagnosis.

DIF: Cognitive Level: Application REF: p. 79|Box 6-3

OBJ: Theory #5 TOP: Expected Outcomes

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. Nurses design interventions that are appropriate for a patient that are:

a.	based on the primary care provider’s orders and the medical diagnosis.
b.	expected to help the patient meets the goals most quickly.
c.	used to evaluate whether the nursing care plan should be revised.
d.	based on cost effectiveness and staff availability.

ANS: B

Nursing interventions are based on nursing diagnoses and are those most likely to assist the patient in meeting outcomes related to those diagnoses.

DIF: Cognitive Level: Comprehension REF: p. 79|Box 6-3

OBJ: Theory #2 TOP: Care Delivery

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. Before performing a catheterization, the inexperienced nurse should:

a.	close the door or curtains to provide the patient with privacy.
b.	provide necessary education and explanation of the procedure to the patient.
c.	observe rules of Standard Precautions to protect herself from exposure to blood or body fluids.
d.	review the agency’s procedure manual for the accepted way of performing the procedure.

ANS: D

Reviewing the procedure manual should occur before the inexperienced nurse explains to the patient, provides privacy, or observes Standard Precautions.

DIF: Cognitive Level: Application REF: p. 75 OBJ: Clinical Practice #2

TOP: Standards for All Nursing Procedures

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. During morning care in a skilled nursing facility, the student nurse notices that the patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first:

a.	position the patient to lie on his side, document it, and inform the head nurse.
b.	position the patient on his side and encourage him to massage around the area.
c.	report to the primary care provider so that the nursing care plan can be revised.
d.	tell the nursing assistant to change the patient’s position every 2 hours.

ANS: A

This change in the patient’s position with documentation is the initial intervention. The discovery of an open lesion requires a change in the nursing plan.

DIF: Cognitive Level: Analysis REF: p. 77 OBJ: Theory #2

TOP: Care Delivery KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. A review of a patient’s nursing care plan before beginning care allows the nurse to:

a.	make revisions in the plan as indicated by the shift report.
b.	use critical thinking skills to organize care for the patient.
c.	begin nursing interventions without needing an initial assessment.
d.	skip the shift report and begin with the initial assessment.

ANS: B

Reviewing the patient’s care plan gives the nurse a starting point for organizing care.

DIF: Cognitive Level: Comprehension REF: p. 75 OBJ: Theory #2

TOP: Planning KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The nurse giving a patient a back massage is performing an intervention considered to be:

a.	a dependent nursing action.
b.	an independent nursing action.
c.	an interdependent nursing action.
d.	a semi-dependent nursing action.

ANS: B

An independent nursing action does not require a primary care provider’s order, but it does require critical thinking and nursing judgment. Giving a back massage would be an independent nursing action.

DIF: Cognitive Level: Comprehension REF: p. 74 OBJ: Theory #2

TOP: Care Delivery KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The nurse administering a medication to a patient is performing an intervention that is:

a.	an independent nursing action.
b.	an interdependent nursing action.
c.	a semi-dependent nursing action.
d.	a dependent nursing action.

ANS: D

The administration of a medication is a dependent nursing action because giving medication requires a primary care provider’s order.

DIF: Cognitive Level: Comprehension REF: p. 74 OBJ: Theory #2

TOP: Care Delivery KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The nurse caring for a group of patients would show cultural sensitivity to assign an older male nursing assistant to the care of:

a.	a 45-year-old white male patient with uncontrolled diabetes.
b.	a 50-year-old Hispanic man with a broken leg.
c.	a 55-year-old Japanese man with irritable bowel syndrome.
d.	a 60-year-old Muslim woman with pneumonia.

ANS: C

Older Japanese men may resist care given by a younger person or a female.

DIF: Cognitive Level: Analysis REF: p. 75 OBJ: Theory #1

TOP: Cultural Considerations KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

1. In assigning tasks to the nursing assistant, the nurse could appropriately select:

a.	range of motion exercises to lower limbs.
b.	sterile dressing change on a leg wound.
c.	postoperative education to a post-hysterectomy patient.
d.	witnessing of the signature on an operative permit.

ANS: A

Range of motion exercises may be provided by nursing assistants, physical therapy aides, or restorative aides. The nurse performs any invasive procedure, legal document witnessing, and any sterile procedure.

DIF: Cognitive Level: Application REF: p. 75 OBJ: Theory #3

TOP: Delegation KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The nurse is assessing a patient who just returned from a bowel resection 1 hour ago. The nurse notes a dressing over the suture line that is wet with sero sanguineous drainage. The nurse should initially:

a.	perform a sterile dressing change.
b.	document and report the wet dressing to the charge nurse.
c.	reinforce the wet dressing and document.
d.	place a towel on the bed and turn the patient to the operated side.

ANS: C

The general rule is that the initial dressing change is performed by the surgeon who will give further orders pertinent to future dressing changes. The dressing should be reinforced with sterile materials; findings should be documented and reported to the charge nurse.

DIF: Cognitive Level: Analysis REF: p. 74 OBJ: Theory #3

TOP: Initial Dressing Change KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

1. The nurse coming on duty has received a report that an IV of 1000 mL of 5% glucose in 0.9% normal saline is running at a rate of 50 mL an hour to be followed by another 1000 mL to be run at the same rate. The reporting nurse states that the second IV should be hung at 9:00 AM. The prudent nurse should: (Select all that apply.)

a.	hang the next 1000 mL when the first is finished.
b.	check to label on the present IV.
c.	confirm the flow rate.
d.	check the order for the IVs.
e.	speed up the flow so that the IV will be completed by 9:00 AM.

ANS: B, C, D

The nurse should check the order and the flow rate, and the amount and type of fluid to follow for accuracy, and not depend on the handoff report.

DIF: Cognitive Level: Analysis REF: p. 73 OBJ: Theory #2

TOP: Care Delivery KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The purpose of the evaluation step of the nursing process is to: (Select all that apply.)

a.	determine if outcomes have been reached and the goals are met.
b.	compare actual outcomes with expected outcomes.
c.	identify inefficient care given by assigned staff.
d.	confirm that nursing interventions are effective.
e.	ensure that the facility has not put itself at risk for litigation.

ANS: A, B, D

Evaluation attempts to determine if the outcomes have been reached and that the interventions being used are effective. Evaluation also demonstrates if the actual outcomes agree with the expected outcomes in the nursing care plan.

DIF: Cognitive Level: Comprehension REF: p. 77 OBJ: Theory #5

TOP: Nursing Process KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. Standards of care are set by: (Select all that apply.)

a.	the state’s nurse practice act.
b.	professional medical association standards.
c.	the facility’s policies and procedures.
d.	the primary care provider in charge of the patient’s treatment.
e.	the director of nurses and the agency administrator.

ANS: A, B, C

Standards of care are set by the state’s nursing practice act, professional association standards, and the facility’s policies and procedures.

DIF: Cognitive Level: Comprehension REF: p. 75 OBJ: Theory #3

TOP: Standards of Care KEY: Nursing Process Step: Planning

MSC: NCLEX: N/A

COMPLETION

1. The agency-wide process that takes into consideration nursing audits and compliance to standards of every department is the ______________________.

ANS:

outcome-based quality improvement

The outcome-based quality improvement is the agency-wide evaluation to determine if patient needs are being met according to standards in every department of the facility.

DIF: Cognitive Level: Knowledge REF: p. 77 OBJ: Theory # 6

TOP: Outcome-Based Quality Improvement KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. When an agency is using a clinical pathway/care map protocol of health care provision, there is no need for a ________________.

ANS:

nursing care plan

The nursing care plan is not part of the patient’s medical record when an interdisciplinary care approach is used.

DIF: Cognitive Level: Comprehension REF: p. 74 OBJ: Theory #2

TOP: Clinical Pathway KEY: Nursing Process Step: Planning

MSC: NCLEX: N/A

Chapter 07: Documentation of Nursing Care

Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition

MULTIPLE CHOICE

1. The nurse is with a patient who complains of severe pain, documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patient’s primary care provider requesting that the primary care provider examines the patient for unexpected complications. This documentation by the nurse is likely to:

a.	cause the primary care provider to come to the attention of the hospital administration.
b.	be questioned by the nurse’s supervisor for time inefficiency.
c.	be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain.
d.	justify insurance reimbursement for an extended duration of hospitalization for the patient.

ANS: D

Documentation of complications or a patient’s changing condition is used by insurance companies to justify payments for hospitalization. Documentation also serves as evidence of standards of care in a court of law.

DIF: Cognitive Level: Application REF: p. 84 OBJ: Theory #4

TOP: Purposes of Documentation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, because it is her personal property. An appropriate response would be:

a.	“Certainly. This hospital doesn’t need to keep it if you are leaving and will not be returning here.”
b.	“You are entitled to the information in your medical record, but the medical record is the property of the hospital. I will see about having a copy made for you.”
c.	“The information in your medical record is confidential, and you cannot leave this facility with it.”
d.	“Because you are leaving against the medical advice of your primary care provider, you may not have the medical record.”

ANS: B

The medical record is the property of the facility, but the patient has a legal right to the information in it even if she is leaving AMA.

DIF: Cognitive Level: Application REF: p. 86 OBJ: Theory #3

TOP: The Medical Record KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

a.	motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience.
b.	doing appropriate research about nursing care as long as information is not divulged.
c.	violating the confidentiality of the patient’s record.
d.	neglecting the assigned patient load and should read the unassigned patient’s medical record only after his assigned work is completed.

ANS: C

A person reading a patient’s chart who is not involved in the patient’s care is in violation of confidentiality. Protecting the patient’s privacy is of prime importance.

DIF: Cognitive Level: Comprehension REF: p. 92 OBJ: Theory #3

TOP: The Medical Record KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: “Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication.” This documentation is:

a.	an example of charting by exception.
b.	evidence of the use of the nursing process.
c.	using the problem-oriented medical record (POMR) format.
d.	usually entered on a flow sheet for treatments and vital signs.

ANS: B

The nursing process is evident in this documentation. Assessment, interventions, and evaluation are all noted.

DIF: Cognitive Level: Analysis REF: p. 92 OBJ: Theory #2

TOP: Methods of Charting KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

a.	“4 cm reddened area over sacrum. Skin intact, warm, and dry.”
b.	“Taking fluids poorly, but more than yesterday.”
c.	“Apparently comfortable all night. Offers no complaints of pain.”
d.	“Patient says she is still slightly nauseated, would like to try some toast and tea.”

ANS: A

Provision of specific objective data—size, location, and characteristics of the patient’s skin—is clear and brief and informative.

DIF: Cognitive Level: Comprehension REF: p. 95 OBJ: Clinical Practice #2

TOP: The Charting Process KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. A nurse enters a notation in a patient’s medical record but then discovers that the notation was made in the wrong chart. The nurse correctly:

a.	draws a single line through the notation so that it is still readable and writes “mistaken entry,” his signature, and the date and time.
b.	removes the page on which the error is located and documents the other correct notes.
c.	blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin “wrong patient,” his signature, and the date and time.
d.	whites out the wrong entry and writes the note in the chart of the correct patient.

ANS: A

When an error is made, no attempt to hide or obliterate the error should be made, because this may be questioned in a court of law.

DIF: Cognitive Level: Application REF: p. 94|Box 7-4

OBJ: Theory #6 TOP: Charting Error Corrections

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. A resident in a skilled nursing facility for a short term rehabilitation following a hip replacement says to the nurse, “I don’t want to have you draw any more blood for those useless tests.” When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:

a.	“Refuses to have blood drawn. Doctor notified.”
b.	“Refuses to have blood drawn; says tests are ‘useless.’ Doctor notified.”
c.	“Doctor notified of failure to draw ordered blood work.”
d.	“Blood not drawn because tests are no longer desired by patient.”

ANS: B

When a patient refuses a treatment, the nurse should document the exact words of the patient regarding why the patient is refusing care.

DIF: Cognitive Level: Application REF: p. 94|Box 7-4

OBJ: Clinical Practice #2 TOP: What to Document

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:

a.	“Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch.”
b.	“Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch.”
c.	“Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse.”
d.	“Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids.”

ANS: D

When documenting a sign or symptom, the nurse should include the quality (levels 7 to 8), chronology (after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms.

DIF: Cognitive Level: Application REF: p. 94|Box 7-2

OBJ: Clinical Practice #2 TOP: The Charting Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. In a medical record for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse documents “Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge.” This type of documentation is an example of:

a.	charting by exception.
b.	narrative style.
c.	a problem-oriented medical record (POMR).
d.	the case management system.

ANS: C

The POMR focuses on a patient problem or nursing diagnosis and typically uses the SOAP (subjective, objective, assessment, plan) format as shown here.

DIF: Cognitive Level: Application REF: p. 88 OBJ: Theory #4

TOP: Methods of Charting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) documentation is that charting by exception:

a.	is well suited to defending nursing actions in court.
b.	contains important data certain to be noted in the narrative sections.
c.	allows staff to learn the system quickly and easily.
d.	highlights abnormal data and patient trends.

ANS: D

Charting by exception enables staff to see notation of changes in a patient’s condition at a glance.

DIF: Cognitive Level: Comprehension REF: p. 90 OBJ: Theory #4

TOP: Methods of Charting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. If an agency is using computer-assisted charting, the nurse is responsible for:

a.	learning the passwords of the staff nurses and primary care providers so that they can communicate with one another.
b.	guarding the confidentiality of the patient record by not leaving the patient screen “on” if he leaves the terminal.
c.	patient education to input information about herself, such as intake and output or symptoms the patient may experience.
d.	choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation.

ANS: B

Confidentiality of computer records is as important as that of the paper medical record. Nurses must also be protective of their user passwords.

DIF: Cognitive Level: Comprehension REF: p. 92|Box 7-1

OBJ: Theory #4 TOP: Methods of Charting

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

a.	at the end of the shift so that the nurse can give his full attention and time to the patient’s needs during the shift.
b.	a nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities.
c.	at least three times during the shift: at the beginning, in the middle, at the end, and as needed.
d.	an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.

ANS: D

An initial assessment should be performed at the beginning of the shift and promptly documented. It will determine the plan and priorities. Documentation should be done as close to the time of occurrence as possible.

DIF: Cognitive Level: Application REF: p. 94|Box 7-4

OBJ: Theory #1 TOP: The Charting Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. The nurse uses the flow sheet in patient care documentation primarily:

a.	to track routine assessments, treatments, and frequently given care.
b.	to eliminate written narratives and to save time.
c.	in computer-assisted charting to create visual graphs showing change.
d.	to improve continuity of care and exchange of information among disciplines.

ANS: A

Flow sheets are a time saver but do not eliminate narrative charting. They are used to document information that is routine and that would be “lost” in a narrative note.

DIF: Cognitive Level: Comprehension REF: p. 86 OBJ: Theory #4

TOP: Flow Sheets KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

1. When the nurse documents in narrative or source-oriented format about the patient’s condition and the nursing care provided, it is appropriate for him to record:

a.	“Patient will go to physical therapy after lunch.”
b.	“Diabetes in excellent control. Continue with current insulin schedule.”
c.	“I gave the patient a thorough bath and cut her fingernails.”
d.	“To x-ray by wheelchair at 10:30 AM IV infusing in left arm.”

ANS: D

Documentation that includes specific information regarding time, method of travel, destination, and current status (that an IV medication is infusing) is a clear example of source-oriented charting.

DIF: Cognitive Level: Application REF: p. 86 OBJ: Theory #4

TOP: Source-Oriented Charting KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. The nurse understands that a face sheet contains information pertaining to:

a.	serial measurements and observations, such as temperature, pulse, respiration, blood pressure, and weight.
b.	plan of care for the patient, including nursing diagnoses, goals/expected outcomes, and nursing interventions.
c.	written report of the nursing process, record of interventions implemented, and the patient’s response to them.
d.	patient data, including patient’s name, address, phone number, insurance company, and admitting diagnosis.

ANS: D

The type of information contained on a face sheet includes patient data, including the patient’s name, address, phone number, next of kin, hospital identification number, religious preference, place of employment, insurance company, occupation, name of admitting physician, and admitting diagnosis.

DIF: Cognitive Level: Comprehension REF: p. 85|Table 7-1

OBJ: Theory #4 TOP: Documentation Forms

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. A nurse understands that the primary care provider’s directives for patient care are also referred to as the:

a.	history and physical.
b.	primary care provider’s orders.
c.	progress notes.
d.	face sheet.

ANS: B

The primary care provider’s directives for patient care are the same as the physician’s orders.

DIF: Cognitive Level: Knowledge REF: p. 85|Table 7-1

OBJ: Clinical Practice #4 TOP: The Medical Record

KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

1. A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

a.	nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career.
b.	actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared.
c.	nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor.
d.	nurse has not violated the confidentiality of the patient because the patient is terminal; sharing this information will not harm the patient.

ANS: C

As a legal record, the contents of the medical record must be kept confidential and can be given out only with the patient’s written consent because it contains personal information regarding the patient. Only those health professionals caring directly for the patient, or those involved in research or education, should have access to the chart. Protecting the privacy of the patient is of prime importance. Patient information is not discussed with others who are not directly involved in the patient’s care.

DIF: Cognitive Level: Application REF: p. 92 OBJ: Theory #3

TOP: Patient Confidentiality KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

a.	effective communication.
b.	informatics.
c.	familiarity with medical terms.
d.	writing nursing care plans.

ANS: B

The Quality and Safety Education for Nurses (QSEN) project has identified informatics as an important pre-licensing skill.

DIF: Cognitive Level: Knowledge REF: p. 92 OBJ: Theory #4

TOP: Informatics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

1. Advantages of source-oriented or narrative charting include all of the following except that it:

a.	encourages documentation of normal and abnormal findings.
b.	gives information on the patient’s condition and care in chronological order.
c.	indicates the patient’s baseline condition for each shift.
d.	includes aspects of all steps of the nursing process.

ANS: A

A disadvantage of source-oriented, or narrative, charting is that it encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information.

DIF: Cognitive Level: Comprehension REF: p. 88 OBJ: Theory #4

TOP: The Charting Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. Which examples of documentation would be most informative to transcribe to the patient’s medical record?

a.	“Patient consumed two slices of bread and a cup of coffee at breakfast.”
b.	“Patient does not appear to be hungry after consuming breakfast.”
c.	“Patient ate a small amount of bread and drank a little coffee for breakfast.”
d.	“Patient ate well for breakfast, lunch, and dinner and seems content.”

ANS: A

Use of the words “appears to” or “seems” in phrases such as “appears to be resting” should be avoided. Document the behavior; the patient either is or is not resting. Words that have ambiguous meanings and slang should not be used in documentation. For example, how much is “a little,” “a small amount,” or a “large amount”? What do phrases such as “ate well” and “taking fluids poorly” mean? Although such words give a general idea of what is meant, they are not specific.

DIF: Cognitive Level: Application REF: p. 95 OBJ: Theory #4

TOP: Source-Oriented Charting KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. The electronic medical record was set up as a goal of the Stimulus Law that President Obama signed in 2009, for the purpose of providing a:

a.	comprehensive plan of care for all patients.
b.	comprehensive record of a patient’s history and care across all facilities and admissions.
c.	comprehensive document of health care costs.
d.	comprehensive plan to allow patient access to medical records.

ANS: B

An electronic health record (EHR) is a computerized comprehensive record of a patient’s history and care across all facilities and admissions. This type of record has been set up as a goal of the Stimulus Law that President Obama signed in 2009. Health care agencies are mandated to use electronic documentation of patient care (Centers for Medicare and Medicaid Services, 2015).

DIF: Cognitive Level: Comprehension REF: p. 90 OBJ: Theory #1

TOP: Computer-Assisted Charting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

MULTIPLE RESPONSE

1. Advantages of the problem-oriented medical record (POMR) are that this method of documentation: (Select all that apply.)

a.	promotes the problem-solving approach.
b.	formats documentation into chronological order.
c.	makes tracking trends in patient care easy.
d.	allows for easy auditing of patient records to evaluate staff performance.
e.	reinforces application of the nursing process.

ANS: A, D, E

POMR promotes problem solving with the reinforcement of the nursing process. This method allows for easy auditing of patient records.

DIF: Cognitive Level: Comprehension REF: p. 88 OBJ: Theory #4

TOP: Problem-Oriented Charting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. The method of computer-assisted charting: (Select all that apply.)

a.	improves communication between departments.
b.	is less costly to educate personnel to the method.
c.	speeds reimbursement for services.
d.	allows electronic records to be retrieved more quickly.
e.	allows entries to be made at point of care.

ANS: A, C, D, E

Computerized charting improves communication between departments, speeds reimbursement for services and retrieval of records, and allows entries to be made quickly at the point of care. It is more expensive to educate personnel in the use of computers than in other forms of documentation.

DIF: Cognitive Level: Knowledge REF: p. 90 OBJ: Theory #4

TOP: Documentation KEY: Nursing Process Step: Implementation

MSC: NCLEX: N/A

1. Helpful cultural information the nurse should include on the admission note is: (Select all that apply.)

a.	primary language spoken.
b.	number of children in the immediate household.
c.	beliefs about causality of illness.
d.	level of English literacy.
e.	dietary concerns.

ANS: A, C, D, E

Information relative to primary language, beliefs about cause of illness, level of English literacy, and dietary concerns are helpful items to include on the admission note.

DIF: Cognitive Level: Comprehension REF: p. 93 OBJ: Theory #1

TOP: Cultural Information KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

COMPLETION

1. Documentation that follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses’ progress notes is _______ charting.

ANS: PIE(problem identification, intervention, and evaluation)

DIF: Cognitive Level: Knowledge REF: p. 89 OBJ: Theory #2

TOP: Documentation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. Health care professionals assigned to a patient require access to the medical record to review information and to document care given. All contents of the medical record must be kept ___________. The contents of the medical record should not be discussed with persons who are not involved in the care of the patient.

ANS:

confidential

The nurse needs to be able to identify what confidentiality entails.

DIF: Cognitive Level: Knowledge REF: p. 92 OBJ: Theory #3

TOP: Confidentiality KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

1. The nurse explains that should a patient return to the hospital for treatment within _______ years, the medical record can be retrieved from medical records for review.

ANS:

10

Medical records are kept in the health information department of a hospital for a period of 10 years.

DIF: Cognitive Level: Knowledge REF: p. 86 OBJ: Theory #3

TOP: Storage of Medical Records KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

1. When using a case management system of charting a __________, an unexpected event in the patient’s condition is documented on the back of the pathway sheets.

ANS:

variance

A variance is an unexpected event in the patient’s course of care. An example would be a healing wound that was complicated by an infection.

DIF: Cognitive Level: Knowledge REF: p. 95|Figure 7-9

OBJ: Theory #4 TOP: Variances KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A