Question 1

A nurse mistakenly gives a client an additional dose of medication.Which of these actions should the nurse take?

Accepted Answer

A) Notify the pharmacy and the client's health care provider. 
B) Complete an incident report,and place a copy in the client's chart. 
C) Document in the nurse's notes the name and dosage of the medication,time given,client's response,and the name of the health care provider and the time this person was notified. 
D) Report the incident to the immediate supervisor. 
A) Notify the pharmacy and the client's health care provider. 
B) Complete an incident report,and place a copy in the client's chart. 
C) Document in the nurse's notes the name and dosage of the medication,time given,client's response,and the name of the health care provider and the time this person was notified. 
D) Report the incident to the immediate supervisor.

Question 2

Advance directives differ from informed consent in that advance directives:

Accepted Answer

A) are guidelines to be used only if a client cannot make medical decisions for him- or herself 
B) are only used for specific procedures and expire after the procedure is performed 
C) can be obtained from a client who is sedated,while informed consent cannot 
D) only apply to medical treatments and interventions and cannot be used to direct future nursing care 
A) are guidelines to be used only if a client cannot make medical decisions for him- or herself 
B) are only used for specific procedures and expire after the procedure is performed 
C) can be obtained from a client who is sedated,while informed consent cannot 
D) only apply to medical treatments and interventions and cannot be used to direct future nursing care

Question 3

The nurse performs an initial assessment of a client's physiologic needs followed by assessment of higher-level needs.This is an example of:

Accepted Answer

A) the body systems model 
B) functional health patterns 
C) the hierarchy of needs 
D) human response patterns 
A) the body systems model 
B) functional health patterns 
C) the hierarchy of needs 
D) human response patterns

Question 4

Which of the following statements about the client Kardex is true?

Accepted Answer

A) Only nursing orders are recorded on it. 
B) Personal data such as sex,age,marital status,and religious preference are noted on it. 
C) It is part of the medical record. 
D) It is sent home with the client upon discharge. 
A) Only nursing orders are recorded on it. 
B) Personal data such as sex,age,marital status,and religious preference are noted on it. 
C) It is part of the medical record. 
D) It is sent home with the client upon discharge.

Question 5

What is the relationship between nursing practice acts and documentation?

Accepted Answer

A) Nursing practice acts establish guidelines for practice and standards of care that are evidenced by documentation. 
B) Documentation ensures safe practice. 
C) Documentation and nursing practice requirements differ from state to state. 
D) Nursing practice acts are independent of documentation requirements. 
A) Nursing practice acts establish guidelines for practice and standards of care that are evidenced by documentation. 
B) Documentation ensures safe practice. 
C) Documentation and nursing practice requirements differ from state to state. 
D) Nursing practice acts are independent of documentation requirements.

Question 6

The nurse is gathering data about the client through physical examination and observation.This is an example of:

Accepted Answer

A) comprehensive data 
B) thorough data 
C) objective data 
D) subjective data 
A) comprehensive data 
B) thorough data 
C) objective data 
D) subjective data

Question 7

While giving an end-of-shift report at 1915,a nurse realizes that a client's physical therapy session that occurred at 1030 was not documented.Which of the following is the correct method for adding this information to the client record?

Accepted Answer

A) Ask the oncoming nurse to make the notation for you. 
B) Date and time the entry for 1915;then write "Late Entry (date-1030)" before making the addition. 
C) Do not add the information to the chart,but complete an incident report. 
D) Do nothing,since the physical therapist documented the session in the multidisciplinary progress notes. 
A) Ask the oncoming nurse to make the notation for you. 
B) Date and time the entry for 1915;then write "Late Entry (date-1030)" before making the addition. 
C) Do not add the information to the chart,but complete an incident report. 
D) Do nothing,since the physical therapist documented the session in the multidisciplinary progress notes.

Question 8

A facility's admission database divides client data by body systems and includes a section on psychosocial aspects of client status.This type of grouping similar data together into categories is called:

Accepted Answer

A) the medical model 
B) an assessment model 
C) data clustering 
D) health management 
A) the medical model 
B) an assessment model 
C) data clustering 
D) health management

Question 9

Reimbursement from insurance companies can be denied or reduced when a nurse fails to document which of the following?

Accepted Answer

A) client phone calls 
B) nursing diagnoses 
C) equipment used or procedures performed 
D) physician rounds 
A) client phone calls 
B) nursing diagnoses 
C) equipment used or procedures performed 
D) physician rounds

Question 10

Which functional health pattern would be MOST appropriate to use to categorize this data: client is awake,alert,and oriented.

Accepted Answer

A) sleep and rest pattern 
B) health management pattern 
C) cognitive and perceptual pattern 
D) activity and exercise pattern. 
A) sleep and rest pattern 
B) health management pattern 
C) cognitive and perceptual pattern 
D) activity and exercise pattern.

Question 11

The multidisciplinary and standard plans of care for specific case situations have the overall goal of to improve the quality and efficiency of client care.This is an example of:

Accepted Answer

A) critical pathways 
B) goal-oriented care plans 
C) linear care directories 
D) multidisciplinary action diagrams 
A) critical pathways 
B) goal-oriented care plans 
C) linear care directories 
D) multidisciplinary action diagrams

Question 12

Which statement BEST explains how a framework can be helpful for collecting assessment data?

Accepted Answer

A) The framework lists every question to ask the client so that the nurse will not forget. 
B) The framework allows the nurse to organize the data and helps determine the priority focus. 
C) Each nurse creates his or her own framework so that all of the assessments are the same. 
D) The framework will provide the nurse with the appropriate interventions to implement. 
A) The framework lists every question to ask the client so that the nurse will not forget. 
B) The framework allows the nurse to organize the data and helps determine the priority focus. 
C) Each nurse creates his or her own framework so that all of the assessments are the same. 
D) The framework will provide the nurse with the appropriate interventions to implement.

Question 13

Which of these terms is used when goals are not met or interventions are not performed within the established time frame while using a critical pathway?

Accepted Answer

A) critical events 
B) exception charting 
C) incident reports 
D) variances 
A) critical events 
B) exception charting 
C) incident reports 
D) variances

Question 14

A client has been admitted with a history of dizzy spells and nausea.The client's blood pressure is highly variable with an elevated temperature on 3 successive days.The physician has ordered vital-sign monitoring,including temperature,heart rate,respirations,and blood pressure every 4 hours.What type of assessment is this type of monitoring called?

Accepted Answer

A) comprehensive 
B) focused 
C) ongoing 
D) primary 
A) comprehensive 
B) focused 
C) ongoing 
D) primary

Question 15

A nurse is completing a client's initial admission database by asking the client questions about his past and current state of health,family history,and physical exam.These actions are part of which step of the nursing process?

Accepted Answer

A) assessment 
B) diagnosis 
C) evaluation 
D) planning 
A) assessment 
B) diagnosis 
C) evaluation 
D) planning

Question 16

A client has a nursing diagnosis of Knowledge deficit (insulin injection technique)related to misinterpretation of information as evidenced by inaccurate return demonstration of self-injection.After several teaching sessions the client can self-inject insulin correctly and confidently.This nursing diagnosis is removed from the plan of care and others are addressed.What type of planning is this called?

Accepted Answer

A) discharge 
B) goal 
C) initial 
D) ongoing 
A) discharge 
B) goal 
C) initial 
D) ongoing

Question 17

When a nurse completes a client's discharge summary,which of these data should be included?

Accepted Answer

A) intervention and education outcomes 
B) problems encountered with the client's family 
C) number of incident reports involving the client 
D) results of specialized treatments and diagnostic tests 
A) intervention and education outcomes 
B) problems encountered with the client's family 
C) number of incident reports involving the client 
D) results of specialized treatments and diagnostic tests

Question 18

The nurse is planning to initiate a phone call to the client's physician regarding a change in status.Which of the following should the nurse ensure would be done prior to making the call? (Select all that apply. )

Accepted Answer

A) Ensure that all lab reports are back. 
B) Ask another nurse their opinion prior to calling. 
C) Ask the charge nurse to complete the call for you. 
D) Wait until the end of the shift and consult with the next nurse. 
E) Have the client's assessment data available.
F)Minimize the chance of interruptions during the call. 
A) Ensure that all lab reports are back. 
B) Ask another nurse their opinion prior to calling. 
C) Ask the charge nurse to complete the call for you. 
D) Wait until the end of the shift and consult with the next nurse. 
E) Have the client's assessment data available.
F)Minimize the chance of interruptions during the call.

Question 19

A goal for a client who has the nursing diagnosis Anxiety related to hospitalization is "The client will verbalize end or alleviation of periods of anxiety within 2 days of hospitalization." What type of goal does this statement represent?

Accepted Answer

A) focused 
B) long-term 
C) ongoing 
D) short-term 
A) focused 
B) long-term 
C) ongoing 
D) short-term

Question 20

Which of these statements about informed consent and documentation is TRUE?

Accepted Answer

A) Clients who have been sedated must have the consent form witnessed by a family member. 
B) Clients who decline to have any specific treatment performed are not required to sign an informed consent form. 
C) There is no legal requirement for informed consent to be written. 
D) Informed consent must be obtained by a health care professional. 
A) Clients who have been sedated must have the consent form witnessed by a family member. 
B) Clients who decline to have any specific treatment performed are not required to sign an informed consent form. 
C) There is no legal requirement for informed consent to be written. 
D) Informed consent must be obtained by a health care professional.

Exam 9: Nursing Processdocumentationinformatics

A nurse mistakenly gives a client an additional dose of medication.Which of these actions should the nurse take?

Advance directives differ from informed consent in that advance directives:

The nurse performs an initial assessment of a client's physiologic needs followed by assessment of higher-level needs.This is an example of:

Which of the following statements about the client Kardex is true?

What is the relationship between nursing practice acts and documentation?

The nurse is gathering data about the client through physical examination and observation.This is an example of:

While giving an end-of-shift report at 1915,a nurse realizes that a client's physical therapy session that occurred at 1030 was not documented.Which of the following is the correct method for adding this information to the client record?

A facility's admission database divides client data by body systems and includes a section on psychosocial aspects of client status.This type of grouping similar data together into categories is called:

Reimbursement from insurance companies can be denied or reduced when a nurse fails to document which of the following?

Which functional health pattern would be MOST appropriate to use to categorize this data: client is awake,alert,and oriented.

The multidisciplinary and standard plans of care for specific case situations have the overall goal of to improve the quality and efficiency of client care.This is an example of:

Which statement BEST explains how a framework can be helpful for collecting assessment data?

Which of these terms is used when goals are not met or interventions are not performed within the established time frame while using a critical pathway?

A nurse is completing a client's initial admission database by asking the client questions about his past and current state of health,family history,and physical exam.These actions are part of which step of the nursing process?

When a nurse completes a client's discharge summary,which of these data should be included?

The nurse is planning to initiate a phone call to the client's physician regarding a change in status.Which of the following should the nurse ensure would be done prior to making the call? (Select all that apply. )

A goal for a client who has the nursing diagnosis Anxiety related to hospitalization is "The client will verbalize end or alleviation of periods of anxiety within 2 days of hospitalization." What type of goal does this statement represent?

Which of these statements about informed consent and documentation is TRUE?

Student Nurse Skills for Success

Holistic Care

Nursing History, Education, and Organizations

Legal and Ethical Responsibilities

The Health Care Delivery System

Arenas of Care

Communication

Client Teaching

Life Span Development

Cultural Considerations

Stress, Adaptation, and Anxiety

Loss, Grief, and Death

Wellness Concepts

Self-Concept

Spirituality

Complementary Alternative Therapies

Basic Nutrition

Rest and Sleep

Safety-Hygiene

Infection Controlasepsis

Standard Precautions and Isolation

Bioterrorism

Fluid, Electrolyte, and Acid-Base Balance

Medication Administration and IV Therapy

Assessment

Pain Management

Diagnostic Tests

Basic Procedures

Intermediate Procedures

Advanced Procedures

Anesthesia

Surgery

Oncology

Respiratory System

Cardiovascular System

Hematologic and Lymphatic Systems

Gastrointestinal System

Urinary System

Musculoskeletal System

Neurological System

Sensory System

Endocrine System

Reproductive System

Sexually Transmitted Diseases

Integumentary System

Immune System

Mental Illness

Substance Abuse

The Older Adult

Ambulatory, Restorative, and Palliative Care in Community Settings

Responding to Emergencies

Integration

Prenatal Care

Complications of Pregnancy

The Birth Process

Postpartum Care

Newborn Care

Basics of Pediatric Care

Infants With Special Needs: Birth to 12 Months

Common Problems: 1-18 Years

Filters