Chapter 4 & 5

Question 1

The nurse spills coffee on a patient’s chart while charting. Which action would the nurse take?

Answer 1

Note on the damaged page that the information will be rewritten.
-Something from the chart should not be deleted

Question 2

Which action would the nurse take when completing a variance report for a patient who fell out of bed while unattended?

Answer 2

Add that x-rays were taken of the hip.

Question 3

Which documentation practices can increase the nurse’s risk of being sued for malpractice? Select all that apply.

Answer 3

-Documents a change in one vital but not the other
-Charting in the wrong individuals chart
-Failure to inform HCP of pertinent health history\
-Failure to document healthcare orders

Question 4

The nurse is reinforcing teaching to nursing students about the purposes of documentation. Which information would the nurse include? Select all that apply.

Answer 4

-Provides continuity of care
-Obtains reimbursement for care
-Serves as a record for quality assurance
-Serves as a legal record

Question 5

Which action by the LPN/LVN indicates a correct understanding of the LPN’s/LVN’s role in the nursing process?

Answer 5

Carries out interventions (Can never truly initiate any process, as that is RN jurisdiction)

Question 6

The nurse plans care for an older adult female patient admitted to the medical floor for a right hip fracture. Which is the most appropriate outcome statement for the patient at this time?

Answer 6

The PT will report pain less then 5/10 this shift.

Question 7

The nurse ambulates a patient with intestinal gas buildup in the hallway to help relieve the discomfort. Which step of the nursing process did the nurse complete?

Answer 7

Implementation

Question 8

The following goal is written in a patient’s care plan: Patient will verbalize three foods allowed on a heart-healthy diet. Which action would the nurse take to evaluate this goal?

Answer 8

Ask the patient to list the items that will be eaten after discharge

Question 9

Which is an appropriate action for the nurse to take when computer charting?

Answer 9

Log off immediately after charting PT information

Question 10

The nurse is providing care to a patient with urinary retention (problems urinating). Which dependent interventions might the nurse expect to perform? Select all that apply.

Answer 10

-Insert a foley catheter
-Administer a diuretic
-Obtain a clean-catch urine sample

Question 11

Which type of nursing care plan (see image) is the nurse using?

Answer 11

Critical pathway

Question 12

The LPN/LVN reviews the nursing diagnosis written on the care plan: “Risk for infection related to a break in the skin.” The phrase “a break in the skin” represents which component of the nursing diagnosis?

Answer 12

Etiology (causative factor due to “related to”)

Question 13

Place the steps of the nursing process in order.

Answer 13

Assessment, Diagnoses, Planning, Implementation, and Evaluation

Question 14

The LPN/LVN reviews a patient’s care plan. Which nursing diagnosis is the priority?

Answer 14

Deficient fluid intake

Question 15

The nurse is contributing data to the care plan from a primary source. Which source did the nurse use?

Answer 15

Patient (anything other then the PT is a secondary source)

Question 16

Evaluate the nurses notes below (see image). Which finding could cause the nurse legal issues?

Answer 16

Leaving blank space in the note.

Question 17

Which actions indicate the nurse understands narrative charting? Select all that apply.

Answer 17

-Chronological order
-From admission to discharge
-Charts w/o the use of medical abbreviation

Question 18

The LPN/LVN observes a patient pacing and believes the patient is anxious. Which initial action would the nurse take?

Answer 18

Validate findings with the PT

Question 19

The nurse changes a dressing and observes a patient’s wound has decreased in size. Where in a problem-oriented medical record would the nurse chart this information?

Answer 19

Progress notes

Question 20

The LPN/LVN is working in home health. Which action would the nurse take?

Answer 20

Document how the PT is progressing in follow up visits

Question 21

The LPN/LVN is assisting the RN who is writing long- and short-term goals. Which step of the nursing process are the nurses working on?

Answer 21

Planning

Question 22

The nurse writes the following in a patient’s chart: “Heart tones strong.” However, the nurse meant to write weak rather than strong. What would the nurse do?

Answer 22

Writes a single horizontal line through strong, initial it, and write weak above

Question 23

Which actions would the nurse take before suctioning a patient who is having problems swallowing? Select all that apply.

Answer 23

-Gather supplies for the procedure
-Explain the procedure to the PT

Question 24

The nurse turns a patient at 7:30 p.m. How would the nurse chart the time in military time? Enter the numeral only. Do not enter the unit.

Answer 24

1930

Question 25

Which expected outcome would the nurse most likely observe written in a patient's care plan?

Answer 25

Patient will rate pain level at a 2 or lower before discharge (it is realistic, measurable, PT performable, and has a time frame)

Question 26

Which situations will cause the nurse to complete an incident report? Select all that apply.

Answer 26

-PT fell during ambulation -Visitor fainted -A new medication was ordered two days ago and is just being administered now -A patient spilled hot coffee on their chest

Question 27

Which safety measures should the nurse take during implementation? Select all that apply.

Answer 27

-Read the PT arm band and have them state their name and birth date -Refer too facility procedures if unsure about a skill -Continue to observe the PT for any problem

Question 28

The nurse listens to a patient's abdomen with a stethoscope and hears active bowel sounds. Which physical assessment technique did the nurse use?

Answer 28

Auscultation

Question 29

The nurse is using SOAP to chart patient care. Which information would the nurse place after the S?

Answer 29

Reports "hard to catch breath when I take a deep breath"

Question 30

The nursing instructor is discussing the concept of critical thinking with a group of nursing students. Which statement indicates that additional teaching is needed?

Answer 30

Students should always follow protocols regardless of patient assessment data. (Nurses should always follow established protocols based on assessment of patient data)

Question 31

A nurse reviews a care plan written for a patient. Which nursing diagnosis should the nurse delete from this plan?

Answer 31

Chronic fatigue syndrome related to poor diet

Question 32

A student nurse is applying nursing process to develop a plan of care for a medical patient admitted for hypertension control. Which option best represents the planning step?

Answer 32

Weight loss to be achieved

Question 33

A nurse is reviewing the patient’s plan of care and determines that the patient has not met the goal. Which action should the nurse take first?

Answer 33

Review the plan of care.

Question 34

A nurse is working collaboratively with an RN to take care of a group of patients. Which step of the nursing process requires collaboration?

Answer 34

Assessment and diagnosis

Question 35

nurse is admitting a patient to the medical unit who states that they have pain as their primary problem. Which question should the nurse ask next?

Answer 35

“On a scale of 1 to 10, how would you rate your pain?”

Question 36

A nurse is reviewing Maslow’s hierarchy of needs. Which option represents the highest level of human need?

Answer 36

Self - actualization

Question 37

A nurse is evaluating the patient’s plan of care upon discharge from the hospital. Which type of goal would the nurse expect to be attained if all needs have been addressed?

Answer 37

Short term

Question 38

A patient with diabetes is being treated for an infected foot wound. Which would be an appropriate short-term goal for this patient?

Answer 38

Demonstrates correct technique for self-injection of insulin

Question 39

A nurse assesses a patient’s vital signs and finds the patient is febrile. Which intervention represents a dependent intervention?

Answer 39

Administer Tylenol.

Question 40

patient has a critical pathway to be used for providing care. Which should the nurse keep in mind when following this plan of care?

Answer 40

Care based on the day of hospitalization

Question 41

A nursing student is preparing a care plan for an assigned patient. What should the nurse include that is least likely to be placed on an individualized plan of care for the same patient?

Answer 41

Impact of laboratory data on selection of an intervention

Question 42

A nurse is reviewing information to use as modifiers for NANDA-I lists. Which modifiers should the nurse identify as being appropriate? Select all that apply.

Answer 42

-Impaired -Deficient -Disturbed

Question 43

A nurse discovers a patient lying on the floor. Which should the nurse write when completing an incident report?

Answer 43

“Found patient lying face down on the floor beside the bed.”

Question 44

A nurse is working in a clinical agency that uses charting by exception. Which notation should not be included in the patient’s chart?

Answer 44

Vital signs stable

Question 45

A patient tells the nurse that there is incorrect information in the health record. What is the initial nursing response?

Answer 45

Patient can provide information to amend the record.

Question 46

A nursing student is working on a care plan for a patient while in the clinical setting. Which action if observed by the nursing instructor warrants immediate action?

Answer 46

Writing notes that contain patient identification number

Question 47

A nurse manager is reviewing patient charting. Which of the following actions may lead to problems?

Answer 47

Report form

Question 48

A nurse is preparing to provide patient teaching related to care and management of casted extremity. Which information is essential for the nurse to include in the teaching plan?

Answer 48

Allow for patients to provide return demonstration.

Question 49

A nurse is providing report to the ongoing shift in a long-term care unit. Which system should the nurse to provide information?

Answer 49

Kardex

Question 50

A nursing instructor is asked to prepare an educational program on incidents that have occurred on a specific care area. Which is the most cost-effective approach for the instructor to use in collecting information to support the educational program?

Answer 50

Complete a database search through the electronic medical record.

Question 51

A resident is being admitted to the skilled nursing facility. Which documentation is required to be completed for this patient?

Answer 51

Minimum data set