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Who may access a client's medical record?

Only those health care
providers who are involved directly in a client’s care may access that client’s medical record.


Information to document


Medication administration

Treatments and responses

Client education


Purposes for medical records include:

communication, legal documentation, financial billing,
education, research, and auditing.


Subjective Data Documentation

direct quotes, within quotation marks, or summarize
and identify the information as the client’s statement.


Objective Data Documentation

Is descriptive and should include what the nurse sees, hears, feels, and


Documentation should include:

Assessments, interventions, and evaluations, not personal opinions or criticism of others’ care.


Narrative Documentation

records information as a sequence of events in a storylike manner.


Charting by exception

standardized forms that identify norms and allows selective
documentation of deviations from those norms.


SOAP notes

S – Subjective data
O – Objective data
A – Assessment (includes a nursing diagnosis based on the assessment)
P – Plan


PIE notes

P – Problem
I – Intervention
E – Evaluation


DAR (Focus Charting)

D – Data
A – Action
R – Response


End of Shift Report Includes

Significant objective information about the client’s health problems.

Proceed in a logical sequence.

Include no gossip or personal opinion.

Relate recent changes in medications, treatments, procedures, and the discharge plan.



Health Insurance Portability and Accountability Act of 1996



protected health information


A nurse is preparing information for change-of-shift report. Which of the following information should
the nurse include in the report?

A. The client’s input and output for the shift

B. The client’s blood pressure from the previous day

C. A bone scan that is scheduled for today

D. The medication routine from the medication administration record

C. is CORRECT: The bone scan is important because the nurse might have to modify the client’s care to accommodate leaving the unit.


A nurse enters a client’s room and finds him sitting in his chair. He states, “I fell in the shower, but I got myself back up and into my chair.” How should the nurse document this in the client’s chart?

A. The client fell in the shower.

B. The client states he fell in the shower and was able to get himself back into his chair.

C. The nurse should not document this information in the chart because she did not witness

the fall.

D. The client fell in the shower but is now resting comfortably.

B. is CORRECT: By writing what the client states, the information is subjective data.


A nursing instructor is reviewing documentation with a group of nursing students. Which of the

following legal guidelines should they follow when documenting in a client’s record? (Select all

that apply.)

A. Cover errors with correction fluid, and write in the correct information.

B. Put the date and time on all entries.

C. Document objective data, leaving out opinions.

D. Use as many abbreviations as possible.

E. Wait until the end of the shift to document.

B. and C. are CORRECT:
The day and time confirm the recording of the correct sequence of events.

Documentation must be factual, descriptive, and objective, without opinions or criticism.


The skin barrier covering a client’s intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the current shift, but it remains intact only when the client is
supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage
from the fistula, so the therapist did not ambulate the client today. The client sat in a chair during lunch with an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having
physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? (Select all that apply.)

A. The physical therapist did not ambulate the client today.

B. The skin barrier’s seal stays on in bed but loosens when the client stands.

C. The client seemed to welcome having a “day off” from physical therapy.

D. The wound care nurse will see the client later today.

E. The client ate all the food on her lunch tray.

A. B. and D. are CORRECT: The oncoming nurse needs to know about any changes in or deviations from the
client’s plan of care, such as missing a physical therapy session.

The current problem about the adhesion of the skin barrier is important information the oncoming nurse needs to know and address.

The oncoming nurse needs to know about any consultations that will take place during the shift.


A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.)

A. Repeat the details of the prescription back to the provider.

B. Have another nurse listen to the telephone prescription.

C. Obtain the prescriber’s signature on the prescription within 24 hr.

D. Decline the verbal prescription because it is not an emergency situation.

E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A., B. and C. are CORRECT: The nurse should repeat the medication’s name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation.

Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication.

The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr).



Absence of illness-producing micro-organisms.
Maintained through aseptic technique (primarily hand hygiene)
Two types - medical & surgical asepsis


Before beginning any task or procedure that requires aseptic technique, health care team
members must check for ____________.

latex allergies


When should nurse use hand hygiene?

Before and after every client contact
After removing gloves
After contact with body fluids
After using the restroom.
Use soap & water for visibly soiled hands


Administering oral medication, managing nasogastric tubes, providing personal hygiene, and performing many other common nursing tasks.

Would you use Medical or Surgical Asepsis?

Medical Asepsis


Parenteral medication administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures.

Would you use Medical or Surgical Asepsis?

Surgical Asepsis


No. 1 measure to reduce the growth and transmission of infectious agents

Hand hygiene


Surgial Asepsis

The use of precise practices to eliminate all micro-organisms from an object or area.
“Sterile technique”


Hand Hygiene Includes

Handwashing with an antimicrobial or plain soap and water
Alcohol based products such as gels, foams, and rinses


Three essential components to handwashing



Medical Asepsis

The use of precise practices to reduce the number, growth, and spread of micro-organisms from an object, person, or area.
"Clean technique"


When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse

A. keep the sterile field at least 6 ft away from the client’s bedside.

B. instruct the client to refrain from coughing and sneezing during the dressing change.

C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.

D. keep a box of facial tissues nearby for the client to use during the dressing change.

C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the
dressing change.


A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.)

A. A bottle containing a sterile solution

B. The edge of the sterile drape at the base of the field

C. The inner wrapping of an item on the sterile field

D. An irrigation syringe on the sterile field

E. One gloved hand with the other gloved hand

C, D and E are CORRECT: The inner wrappings of any objects the nurse dropped onto the sterile field are sterile.
The nurse may touch them with sterile gloves.

Any objects the nurse dropped onto the sterile field during the setup are sterile. The nurse may touch the syringe with sterile gloves.

One sterile gloved hand may touch the other sterile gloved hand because both are sterile.


A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

A. The flap closest to the body

B. The right side flap

C. The left side flap

D. The flap farthest from the body

D is CORRECT: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client’s safety. Unless the nurse pulls the top flap (the one furthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it.


A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.)

A. Apply 3 to 5 mL of liquid soap to dry hands.

B. Wash the hands with soap and water for at least 15 seconds.

C. Rinse the hands with hot water.

D. Use a clean paper towel to turn off hand faucets.

E. Allow the hands to air dry after washing.

B. and D. CORRECT: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 min.

If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands.


A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.)

A. The provider drops a sterile instrument onto the near side of the sterile field.

B. The nurse moistens a cotton ball with sterile normal saline and places it on the

C. The procedure is delayed 1 hr because the provider receives an emergency call.

D. The nurse turns to speak to someone who enters through the door behind the nurse.

E. The client’s hand brushes against the outer edge of the sterile field.

sterile field.

B., C and D are CORRECT: Fluid permeation of the sterile drape or barrier contaminates the field.

Prolonged exposure to air contaminates a sterile field.

Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field.



micro-organisms or microbes that cause infections.


Pathogens include:

Bacteria, Viruses, Fungi, Prions, Parasites



The ability of a pathogen to invade and injure a host


Specific adaptive immunity

allows the body to make antibodies in response to a foreign organism (antigen). This reaction directs against an identifiable micro-organism (specific).


Chain of infection

Causative agent,
portal of exit from host,
mode of transmission,
portal of entry to host, susceptible host


Causative agent



Portal of Exit from host

Respiratory tract
Gastrointestinal tract
Genitourinary tract
Skin/ mucous membranes
Blood/ body fluids


Mode of transmission

Vector borne


Portal of entry to host

Respiratory tract
Gastrointestinal tract
Genitourinary tract
Skin/ mucous membranes
Blood/ body fluids


Susceptible host

Compromised defense mechanisms


Stages of Infection




Healthcare Associate Infection. Infections aquired in a healthcare setting


Iatrogenic infection

related to HAI, but resulting from diagnostic or therapeutic procedure


Signs and Symptoms of infection


Presence of chills, which occur when temperature is rising, and diaphoresis, which occurs when temperature is decreasing

Increased pulse and respiratory rate (in response to the high fever)



Anorexia, nausea, and vomiting

Abdominal cramping and diarrhea

Enlarged lymph nodes (repositories for “waste”)


Inflammatory response

Redness (from dilation of arterioles bringing blood to the area)

Warmth of the area on palpation


Pain or tenderness

Loss of use of the affected part


Airborne precautions require:

o A private room.

o Masks and respiratory protection devices for caregivers and visitors.

o Use an N95 or high-efficiency particulate air (HEPA) respirator if the client is known or suspected to have tuberculosis.

o Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age of the structure.

o If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection.


Droplet precautions require:

A private room or a room with other clients with the same infectious disease, ensuring that each client have their own equipment.

Masks for providers and visitors.


Contact precautions require:

A private room or a room with other clients with the same infection.

Gloves and gowns worn by the caregivers and visitors.

Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag.



Methicillin-resistant Staphylococcus aureus (MRSA) is a strain of Staphylococcus aureus that is resistant to all antibiotics, except vancomycin.



Vancomycin-resistant Staphylococcus aureus is a strain of Staphylococcus aureus that is resistant to vancomycin, but so far is sensitive to other antibiotics specific to a client’s strain.


Precautions during transport:

A surgical mask is placed on the client with an airborne or droplet infection

A draining wound is well covered.


A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of
the following illustrate the rationale for reporting? (Select all that apply.)

A. Planning and evaluating control and prevention strategies

B. Determining public health priorities

C. Ensuring proper medical treatment

D. Identifying endemic disease

A, B, C and E
 Reporting of communicable and infectious diseases assists with planning and
evaluating control and prevention strategies.

 Reporting of communicable and infectious diseases assists with determining public
health policies.

 Reporting of communicable and infectious diseases assists with ensuring proper medical
treatment is available.

 Reporting of communicable and infectious diseases assists with monitoring for
common‑source outbreaks.


A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care?
(Select all that apply.)

A. Place the client in a room that has negative air pressure of at least six exchanges per hour.

B. Wear a mask when providing care within 3 ft of the client.

C. Place a surgical mask on the client if transportation to another department is unavoidable.

D. Use sterile gloves when handling soiled linens.

E. Wear a gown when performing care that may result in contamination from secretions.

B, C and E
 The nurse should wear a mask when within 3 ft of the client.

 The nurse should place a surgical mask on the client during transport to another area of
the facility.

 A gown should be worn if the nurse’s clothing or skin may be contaminated with body
secretions or excretions


A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some
crustings. Which of the following should the nurse suspect?

A. Allergic reaction

B. Ringworm

C. Systemic lupus erythematosus

D. Herpes zoster

D.  Vesicles that follow along a unilateral dermatome can indicate herpes zoster.


A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.)

A. Fever

B. Malaise

C. Edema

D. Pain or tenderness

E. Increase in pulse and respiratory rate

A, B and E
 A fever indicates that the infection is affecting the whole body, and therefore systemic.

 Malaise indicates that the infection is affecting the whole body, and therefore systemic.

 An increase in pulse and respiratory rate indicates that the infection is affecting the
whole body, and therefore systemic.


The infection process (chain of infection)

 „Causative agent

 „Reservoir

 „Portal of exit (means of leaving) from the host

 „Mode of transmission

 „Portal of entry to the host

 „Susceptible host


Seclusion and/or restraint must never be used for:

◯ Convenience of the staff

◯ Punishment for the client

◯ Clients who are extremely physically or mentally unstable

◯ Clients who cannot tolerate the decreased stimulation of a seclusion room


Restraints should:

◯ Never interfere with treatment

◯ Restrict movement as little as is necessary to ensure safety

◯ Fit properly and be as discreet as possible

◯ Be easily removed or changed to decrease the chance of injury and to provide for the greatest level of dignity


Can a nurse place a restraint without a Dr. order?

In an emergency situation in which there is immediate risk to the client or others, the nurse
may place a client in restraints. The nurse must obtain a prescription from the provider as soon as possible in accordance with agency policy (usually within 1 hr).


Restraint prescriptions MUST include:

the reason for the restraint,
the type of restraint,
the location of the restraint, how long the restraint may be used,
and the type of behaviors demonstrated by the client that warrant use of the restraint.


Restraint time limits:

4 hr for an adult,
2 hr for clients ages 9 to 17,
1 hr for clients younger than 9 years of age.
Prescriptions may be renewed, if needed, with a maximum of 24 consecutive hours.


Nursing responsibilities (restraints)

■ Assess skin integrity, and provide skin care per facility protocol, usually every 2 hr.

■ Offer food and fluid.

■ Provide with means for hygiene and elimination.

■ Monitor for vital signs.

■ Offer range of motion of extremities.


RACE (fire response)

◯ R – Rescue: Rescue and protect clients in close proximity to the fire by evacuating them to a safer
location. Ambulatory clients can walk unattended to a safe location.

◯ A – Alarm: Activate the facility alarm system, and then report fire details and location per facility protocol.

◯ C – Contain: Contain the fire by closing doors and windows as well as turning off any sources of oxygen and electrical devices. Clients who are on life support are ventilated with a bag-valve mask.

◯ E – Extinguish: Extinguish the fire if possible using an appropriate fire extinguisher.


3 types of fire extinguisher

☐ Class A is for paper, wood, upholstery, rags, or other types of trash fires.

☐ Class B is for flammable liquids and gas fires.

☐ Class C is for electrical fires.


PASS (fire extinguisher)

☐ P – Pull the pin.

☐ A – Aim at the base of the fire.

☐ S – Squeeze the levers.

☐ S – Sweep the extinguisher from side to side, covering the area of the fire.


A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.)

A. Place a belt restraint on the client when he is sitting on the bedside commode.

B. Keep the bed in low position with full side rails up.

C. Ensure that the client’s call light is within reach.

D. Provide the client with nonskid footwear.

E. Complete a fall-risk assessment.

C, D and E are CORRECT
Ensuring that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the
call light.

Nonskid footwear may keep the client from slipping.

A fall-risk assessment serves as the basis for an individualized plan of care.


A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction?

A. “I will place the client on his side.”

B. “I will go to the nurses’ station for assistance.”

C. “I will administer medications as prescribed.”

D. “I will be prepared to insert an airway.”

B. is CORRECT: During a seizure, the client should not be left alone. The nurse remains with the client and calls for assistance using the call light.


A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse?

A. Extinguish the fire.

B. Pull the fire alarm.

C. Evacuate the clients.

D. Close all open doors on the unit.

C. is CORRECT: Rescue is the first action in the fire response. Protecting and evacuating clients in close proximity to the fire is the priority action.


A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse’s knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses’ station?

A. A 43-year-old client who is postoperative following a laparoscopic cholecystectomy

B. A 61-year-old client being admitted for telemetry to rule out a myocardial infarction

C. A 50-year-old client who is postoperative following an open reduction internal fixation of
the ankle

D. A 79-year-old client who is postoperative following a below-the-knee amputation

D. is CORRECT: This client should be assigned to a room near the nurses’ station due to risk factors that include client’s age, mobility, and balance issues related to the surgery, and potential side effects, such as drowsiness, as a result of analgesic medication.


A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse?

A. Complete a fall-risk assessment.

B. Educate the client and family on fall risks.

C. Complete a physical assessment.

D. Survey the client’s belongings.

A. is CORRECT: The greatest risk to this client is injury due to a fall. Therefore, the priority action
is to determine the client’s fall risk. This will guide the nurse in implementing appropriate safety measures.


Primary Survey

A primary survey is a rapid assessment of life-threatening conditions. It should take no longer than 60 seconds to perform, and should be completed systematically.


The ABCDE principle

◯ Airway/Cervical Spine – This is the most important step in performing the primary survey. If a patent airway is not established, subsequent steps of the primary survey are futile.

◯ Breathing – Once a patent airway is achieved, the presence and effectiveness of breathing should be assessed.

◯ Circulation – Once adequate ventilation is accomplished, circulation is assessed.

◯ Disability – A quick assessment should be performed to determine the client’s level of consciousness.

◯ Exposure – A quick physical assessment should be performed to determine the client’s exposure to adverse elements such as heat or cold.