Test 5 Test Bank Questions Flashcards
Information regarding a patient’ s health status may not be released to non-health care team members because
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
B. Regulations require health care institutions to document evidence of physical and emotional well-being.
C. Reimbursement issues related to patient care and procedures may be of concern.
D. Fragmentation of nursing and medical care procedures may be identified.
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record
A. An interpretation of patient behavior.
B. Objective data that are observed.
C. Lengthy entry using lay terminology.
D. Abbreviations familiar to the nurse.
B. Objective data that are observed.
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception
C. Narrative charting.
A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to
A. Exchange information among health care members.
B. Provide information about patients from one unit to another unit.
C. Ensure proper care for the patient.
D. Aid in the hospital’s quality improvement program.
D. Aid in the hospital’s quality improvement program.
Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principle of: A. Autonomy. B. Fidelity. C. Justice. D. Nonmaleficence.
D. Nonmaleficence
If a nurse decides to withhold a medication
because it might further lower the patient’s blood
pressure, the nurse will be practicing the principle of:
A. Responsibility.
B. Accountability.
C. Competency.
D. Moral behavior.
B. Accountability
A nurse is working with a terminally ill adult patient. The nurse decides to tell the adult children that they need to decide how to advise their father about taking analgesics during the terminal phase of his illness. This step of processing an ethical dilemma is
A. Articulation of the problem.
B. Evaluation of the action.
C. Negotiation of the outcome.
D. Determination of values surrounding the problem.
C. Negotiation of the outcome
A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss A. Living wills. B. Assisted suicide. C. Passive euthanasia. D. Advance directives.
D. Advance Directives
A student nurse employed as a nursing assistant may perform care
A. As learned in school.
B. Expected of a nurse at that level.
C. Identified in the hospital’s job description.
D. Requiring technical rather than professional skills.
C. Identified in the hospital’s job description
You are about to administer an oral medication and you question the dosage. You should
A. Administer the medication.
B. Notify the physician.
C. Withhold the medication.
D. Document that the dosage appears incorrec
B. Notify the physician
. Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is compromised when only one nurse anesthetist is on call?
a. Justice
b. Nonmaleficence
c. Beneficence
d. Fidelity
ANS: A
Justice refers to fairness and is used frequently in discussion regarding access to health care resources. Here the just distribution of resources, in this case pain management, cannot be justly apportioned. Nonmaleficence means “do no harm,” beneficence means “to do good,” and fidelity means “to be true to, or honest.” Each of these principles is partially expressed in the question; however, justice is most comprised because not all laboring patients have equal access to pain management owing to lack of personnel resources
The patient tells the nurse that she is afraid to speak up regarding her desire to end care for fear of upsetting her husband and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient’s cause?
a. Responsibility
b. Advocacy
c. Confidentiality
d. Accountability
ANS: B
Nurses advocate for patients when they support the patient’s cause. A nurse’s ability to adequate advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient’s point of view. Responsibility refers to respecting one’s professional obligations and following through on promises. Confidentiality deals with privacy issues, and accountability refers to owning one’s actions.
The patient’s son requests to view the documentation in his mother’s medical record. What is the nurse’s best response to this request?
a. “I’ll be happy to get that for you.”
b. “You will have to talk to the physician about that.”
c. “You will need your mother’s permission.”
d. “You are not allowed to see it.”
ANS: C
The nurse understands that sharing health information is governed by HIPAA legislation, which defines rights and privileges of patients for protection of privacy. Private health information cannot be shared without the patient’s specific permission. The other three responses either are outright false and/or use poor communication techniques.
When people work together to solve ethical dilemmas, individuals must examine their own values. This step is crucial to ensure that
a. The group identifies the one correct solution.
b. Fact is separated from opinion.
c. Judgmental attitudes are not provoked.
d. Different perspectives are respected.
ANS: D
Values are personal beliefs that influence opinions. To be able to negotiate differences in opinions, the nurse must first be clear about personal values, which will influence behaviors, decisions, and actions. Ethical dilemmas are a problem in that no one right solution exists.
- Ethical dilemmas are common occurrences when caring for patients. The nurse understands that dilemmas are a result of
a. Presence of conflicting values.
b. Hierarchical systems.
c. Judgmental perceptions of patients.
d. Poor communication with the patient.
ANS: A
Poor communication and the hierarchical systems that exist in health care, such as reporting structures within the hospital or the historically unequal relationship between physicians and nurses, may complicate dilemmas. The primary, underlying reason that ethical dilemmas occur is that there are no clear cut, universally accepted solutions to a problem when participating individuals do not share the same values. Without clarification of values, the nurse may not be able to distinguish fact from opinion or value, and this can lead to judgmental attitudes.
The nurse questions a physician’s order to administer a placebo to the patient. The nurse’s action is based on which ethical principle?
a. Autonomy
b. Beneficence
c. Justice
d. Fidelity
ANS: A
Autonomy refers to the freedom to make decisions free of external control. In this case, the nurse questions the physician’s order for a placebo because it supports the patient’s autonomy. Although beneficence, taking a positive action for others, has implications here, it is not the primary operating principle. Justice refers to fairness and is most often used in discussions about access to health care resources. Fidelity refers to the agreement to keep promises.
The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment?
a. Call for an ethical committee consult.
b. Decline the assignment on religious grounds.
c. Scrutinize her own personal values.
d. Convince the family to challenge the directive.
ANS: C
Values develop over time and are influenced by family, schools, religious traditions, and life experiences. The nurse must recognize that no two humans have the same set of experiences, and so differences in values are more likely the norm than the exception. Closer inspection of one’s values may be a step in gaining understanding of another person’s perspective. Calling for a consult, declining the assignment, and convincing the family to challenge the patient’s directive are not ideal resolutions because they do not address the reason for the nurse’s discomfort, which is the conflict between the nurse’s values and those of the patient.
The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept?
a. Teenager in labor who requests epidural anesthesia
b. Middle-aged father of three with an advance directive declining life support
c. Elderly patient who requires dialysis
d. Family elder who is making the decisions for a 30-year-old female member
ANS: D
Autonomy refers to freedom from external control. A person who values autonomy highly may find it difficult to accept situations where the patient is not the primary decision maker regarding his or her care. A teenager requesting an epidural, a father with an advanced directive, and an elderly patient requiring dialysis all describe a patient or family that can make their own decisions and choices regarding care.
Which philosophy of health care ethics would be particularly useful when making ethical decisions about vulnerable populations?
a. Feminist ethics
b. Deontology
c. Bioethics
d. Utilitarianism
ANS: A
Feminist ethics particularly focuses on the nature of relationships, especially those where there is a power imbalance or a point of view that is not routinely accepted. Examples of populations that are considered vulnerable include children, pregnant women, incarcerated persons, and minority groups. Deontology refers to making decisions or “right-making characteristics,” bioethics focuses on consensus building, and utilitarianism speaks to the greatest good for the greatest number.
A nurse argues that we need to reform our health care system because we have a large number of people who are uninsured and end up needing expensive emergent care when low-cost measures could have prevented their illnesses. What ethical framework is she using to make this case?
a. Deontology
b. Ethics of care
c. Feminist ethics
d. Utilitarianism
ANS: D
Utilitarianism is a system of ethics that believes that value is determined by usefulness. This system of ethics focuses on the outcome of the greatest good for the greatest number of people. Deontology would not look to consequences of actions. The ethics of care would not be helpful because consensus on this issue is not achievable. Relationships, which are an important component of feminist ethics, are not addressed in this case.
The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications?
a. Advocacy
b. Responsibility
c. Confidentiality
d. Accountability
ANS: B
Responsibility refers to one’s willingness to respect and adhere to one’s professional obligations. One of the obligations nursing has is to protect patients and communities, including other nurses. If narcotics are missing, this may indicate that patients have not received medications ordered for their care, or it may suggest that a health care professional may be working under the influence. Accountability refers to the ability to answer for one’s actions. Advocacy refers to the support of a particular cause. The concept of confidentiality is very important in health care and involves protecting patients’ personal health information.
A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus’ outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk?
a. Autonomy
b. Fidelity
c. Nonmaleficence
d. Beneficence
ANS: C
Nonmaleficence is the ethical principle that focuses on avoidance of harm or hurt. The nurse must balance risks and benefits of care. Repeated PUBS may place the mother and fetus at risk for infection and increased pain, and may place the mother at risk for increased emotional health stress. Fidelity refers to the agreement to keep promises. Autonomy refers to freedom from external control, and beneficence refers to taking positive actions to help others.
Which issue has increased the attention paid to quality of life concerns in recent history?
a. Health care disparities
b. National movement regarding disabled persons
c. Aging of the population
d. Health care financial reform
ANS: B
Quality of life (QOL) is often at the center of ethical dilemmas, including futile care and DNR discussions, and has been reshaped in the United States. The national effort to better respect the abilities of the disabled has forced Americans to reconsider the definition of QOL. Health care disparities, an aging population, and health care reform are components impacted by personal definitions of quality but are not the underlying reason why QOL discussions have arisen in the United States.
Which patient is most likely to have difficulty with the ethical concept of autonomy?
a. 18-year-old patient in labor
b. 35-year-old patient with appendicitis
c. 53-year-old patient with pancreatitis
d. 78-year-old patient with rheumatoid arthritis
ANS: D
The principle of autonomy refers to freedom from external control and includes commitment to include patients in decisions about their care. People from different generations have differing expectations regarding inclusion in their care. Often, patients who are part of the Silent Generation (born 1925-1945) value formality and authority, which may make them less comfortable with making their own health care decisions.
The nurse is caring for a severely ill patient with AIDS who now requires ventilator support. Which intervention is considered futile?
a. Administering the influenza vaccine
b. Providing oral care every 5 hours
c. Applying fentanyl patches prn for pain
d. Supporting the patient’s lower extremities with pillows
ANS: A
Futile refers to something that is hopeless or serves no useful purpose and in nursing refers to interventions that are unlikely to produce benefit for the patient. Care delivered to a patient at the end of life is focused on pain management and comfort measures. A vaccine is administered to prevent or lessen the likelihood of contracting an infectious disease at some time in the future.
During a severe respiratory epidemic, the local health care organizations decide to give health care providers priority access to ventilators over other members of the community who also need that resource. Which philosophy would give the strongest support for this decision?
a. Feminist ethics
b. Utilitarianism
c. Deontology
d. Ethics of care
ANS: B
Focusing on the greatest good for the most people, the organizations decide to ensure that as many health care workers as possible will survive to care for other members of the community.
Determinations regarding quality of life are
a. Based on a person’s ability to act according to ethical principles.
b. Based on a patient’s self-determination.
c. Value judgments that can vary from person to person.
d. Consistent and stable over the course of one’s lifetime.
ANS: C
Determinations regarding quality of life are value judgments. This means that they are judgments based on what individuals believe is desirable. Beliefs about what people find desirable vary from person to person.
The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. The nurse determines that this is an ethical dilemma not resolved by scientific data. Place the steps the nurse will use to resolve this ethical dilemma in the correct order.
a. The nurse identifies possible solutions or actions to resolve the dilemma.
b. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient’s situation.
c. Health care providers use negotiation to redefine the patient’s plan of care.
d. The nurse evaluates the plan and revises it with input from other health care providers as necessary.
e. The nurse arranges a meeting with health care team members to clarify opinions, values, and facts.
f. The nurse states the problem.
B, E, F, A, C, D
Using the steps of processing an ethical dilemma, once the nurse identifies that an ethical dilemma exists, the nurse then gathers information relevant to the case; clarifies values and distinguishes between fact, opinion, and values; and verbalizes the problem. Then the nurse identifies possible solutions or actions, works with the health care team to negotiate a plan, and evaluates the plan over time.
A newly hired experienced nurse is preparing to change a patient’s abdominal dressing and hasn’t done it before at this hospital. Which action by the nurse is best?
a. Ask another nurse to do it so the correct method can be viewed.
b. Check the policy and procedure manual for the agency’s method.
c. Change the dressing using the method taught in nursing school.
d. Ask the patient how the dressing change has been recently done.
ANS: B
The Joint Commission requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific and need to be accessible on all nursing units. For example, a policy/procedure outlining the steps to follow when changing a dressing or administering medication provides specific information about how nurses are to perform. The nurse being observed may not be doing the procedure according to the agency’s policy or procedure. The procedure taught in nursing school may not be consistent with the policy or procedure for this agency. The patient is not responsible for maintaining the standards of practice. Patient input is important, but it’s not what directs nursing practice.
A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. What action is most appropriate for the nurse to take?
a. Move the book to the upper ledge of the nursing station for easier access.
b. Talk with the nurse manager about the listing being a violation of the Health Insurance Portability and Accountability Act (HIPAA).
c. Use the book as needed while keeping it away from individuals not involved in patient care.
d. Ask the nurse manager to move the book to a more secluded area.
ANS: C
The privacy section of the HIPAA provides standards regarding accountability in the health care setting. These rules include patient rights to consent to the use and disclosure of their protected health information, to inspect and copy their medical record, and to amend mistaken or incomplete information. This document limits who is able to access a patient’s record. It establishes the basis for privacy and confidentiality about patients in any manner. The book is located where only staff would have access. It is not the responsibility of the new nurse to move items used by others on the patient unit. The listing is protected as long as it is used appropriately as needed to provide care. There is no need to move the book to a more secluded area.
A 17-year-old patient, dying of heart failure, wants to have his organs removed for transplantation after his death. What action by the nurse is correct?
a. Prepare the organ donation form for the patient to sign while he is still oriented.
b. Instruct the patient to talk with his parents about his desire to donate his organs.
c. Notify the physician about the patient’s desire to donate his organs.
d. Contact the United Network for Organ Sharing after talking with the patient.
ANS: B
An individual over age 18 may sign the form allowing organ donation upon death. In this situation, the parents would need to sign the form because the teenager is under age 18. The nurse cannot allow the patient to sign the organ donation document because he is younger than age 18. The physician will be notified about the patient’s wishes after the parents agree to donate the organs. The nurse caring for the patient does not contact the United Network for Organ Sharing. A transplant coordinator will be the liaison for this organization.
An obstetrical nurse comes across an automobile accident. The patient seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from her purse to provide an airway. The patient survives and has a permanent problem with his vocal cords, making it difficult to talk. Which statement is true regarding the nurse’s performance?
a. The nurse acted appropriately and saved the patient’s life.
b. The nurse acted within the guidelines of the Good Samaritan Law.
c. The nurse took actions beyond those that are standard and appropriate.
d. The nurse should have just stayed with the patient and waited for help.
ANS: C
An obstetric nurse would not have been trained in performing a tracheostomy or a cricotomy, and doing so would be beyond what she has been trained or educated to do. The nurse did not do what another nurse would have done in the same situation. The nurse is not protected by the Good Samaritan Law because she acted outside of her scope of practice and training. The nurse should have acted within what she was trained and educated to do in this circumstance, not just stay with the patient.
A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering, and for malpractice. What key point will the prosecution attempt to prove?
a. The CPR procedure was done incorrectly.
b. The patient would have died if nothing was done.
c. The patient was resuscitated according to policy.
d. Patients with brittle bones might sustain fractures when chest compressions are done.
ANS: A
Certain criteria are necessary to establish nursing malpractice. In this situation, although harm was caused, it was not because of failure of the nurse to perform a duty according to standards the way other nurses would have performed in the same situation. The nurse would have had to have done the procedure correctly, or the patient most likely would not have survived without any residual problems such as brain damage. The fact that the patient sustained injury as a result of age and physical status does not mean the nurse breached any duty to the patient. The nurse would need to make sure the defense attorney knew that the cardiopulmonary resuscitation (CPR) was done correctly. Without intervention, the patient most likely would not have survived. The prosecution would try to prove that a breach of duty had occurred, which had caused injury, not that cardiopulmonary resuscitation was done correctly. The defense team, not the prosecution, would explain the correlation between brittle bones and rib fractures during CPR.
A recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained?
a. Ask a family member to translate what the nurse is saying.
b. Notify the health care provider that the patient doesn’t speak English.
c. Request an official interpreter to explain the terms of consent.
d. Use hand gestures and medical equipment while explaining in English.
ANS: C
An official interpreter must be present to explain the terms of consent if a patient speaks only a foreign language. A family member or acquaintance who speaks a patient’s language should not interpret health information. Family members can tell those caring for the patient what the patient is saying, but privacy regarding the patient’s condition, assessment, etc., must be protected. There is no way that the nurse can know that the family member is translating exactly what the nurse is saying. Privacy must be ensured and accurate information must be provided to the patient. After consent is obtained for treatment, the health care provider would be notified because little can be done without consent. The health care provider needs to have the translator available during the history and physical, as well as at other times, but the first step is to get a translator to obtain informed consent because this is not an emergency situation. Using hand gestures and medical equipment is inappropriate when communicating with a patient who does not understand the language spoken. Certain hand gestures may be acceptable in one culture and not appropriate in another. The medical equipment may be unknown and frightening to the patient, and the patient still doesn’t understand what is being said.
A pediatric oncology nurse floats to an orthopedic trauma unit. What actions should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse?
a. Provide a complete orientation to the functioning of the entire unit.
b. Determine patient acuity and care the nurse can safely provide.
c. Allow the nurse to choose which meal time she would like.
d. Assign nursing assistive personnel to assist her with care.
ANS: B
Nurses who float need to inform the supervisor of any lack of experience in caring for the type of patients on the nursing unit. They also need to request and receive an orientation to the unit. Supervisors are liable if they give a staff nurse an assignment that he or she cannot safely handle. Before accepting employment, learn the policies of the institution regarding floating, and have an understanding as to what is expected. A basic orientation is needed, whereas a complete orientation of the functioning of the entire unit would take a period of time that would exceed what the nurse has to spend on orientation. Allowing the nurse to choose which meal time she would like is a nice gesture of thanks for the nurse, but it does not enable safe care.
Having nursing assistive personnel may help the nurse complete basic tasks such as hygiene and turning, but it does not enable safe nursing care that she is ultimately responsible for.
While recovering from a severe illness, a hospitalized patient states that he wants to change his living will, which he signed nine months ago. Which response by the nurse is most appropriate?
a. “Check with your admitting health care provider whether a copy is on your chart.”
b. “Have you talked with your attorney recently about a living will?”
c. “Your living will can be changed only once each calendar year.”
d. “Let me check with someone here in the hospital who can assist you.”
ANS: D
Each health care facility has personnel who are familiar with the state laws and can assist the patient in revising a living will. They may be in the admissions or risk management department. Checking with the health care provider about the presence of a living will on the chart has nothing to do with the patient’s desire to change the living will. The question states that the patient wants to change his living will. Asking whether he has talked to his lawyer recently is a closed-ended question that passes the responsibility to someone else, that is, the attorney, and does not address the patient’s current desire to change the living will. It is the nurse’s responsibility to find an appropriate person in the facility to assist the patient. A living will can be changed whenever the patient decides to change it, as long as the patient is competent.
A nurse notices that his neighbor’s preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to their home and talks with the parent available, but the situation continues. What immediate action by the nurse is mandated by law?
a. Talk with both parents about safety needs of their children.
b. Contact the appropriate community child protection agency.
c. Tell the parents that the authorities will be contacted shortly.
d. Take pictures of the children to support the overt child abuse.
ANS: B
The nurse has a duty to report this situation to protect the children. Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action. The person making the report has legal immunity if the report is made in good faith. Talking with the parents is not mandated by law. There is no obligation to tell the parents that they will be reported to authorities. There is no obligation for the nurse to take pictures of the children.
A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that he should not touch these lines, but the patient continues. What is the best action by the nurse at this time?
a. Apply restraints loosely on the patient’s dominant wrist.
b. Try other approaches to prevent the patient from touching these care items.
c. Notify the health care provider that restraints are needed immediately to maintain the patient’s safety.
d. Allow the patient to pull out lines to prove that the patient needs to be restrained.
ANS: B
The risks associated with the use of restraints are serious. A restraint-free environment is the first goal of care for all patients. Many alternatives to the use of restraints are available, and the nurse should try all of them before notifying the patient’s health care provider. The situation states that the patient is touching the items, not trying to pull them out. At this time, the patient’s well-being is not at risk. The nurse will have to check on the patient frequently and then will determine if the health care provider needs to be informed of the situation. Restraints can be used (1) only to ensure the physical safety of the resident or other residents, (2) when less restrictive interventions are not successful, and (3) only on the written order of a health care provider. The health care provider needs to know the situation but also needs to know that all approaches possible have been used before writing an order for restraints. Allowing the patient to pull out any of these items could cause harm to the patient.
A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and a nasogastric tube. What question is priority for the nurse to ask the family before beginning postmortem care?
a. “Do you want to assist in bathing your loved one?”
b. “Is an autopsy going to be done?”
c. “To which funeral home do you want your loved one transported?”
d. “Do you want me to remove the lines and tubes before you see your loved one?”
ANS: B
An autopsy or postmortem examination may be requested by the patient or the patient’s family, as part of an institutional policy, or if required by law. Because the patient’s death occurred as a result of long-term illness, not under suspicious circumstances, and more than 24 hours after admission to the hospital, whether to conduct a postmortem examination would be decided by the family, and consent would have to be obtained from the family. The nurse needs to know the policy to follow regarding removal of lines when an autopsy is to be done. Asking about bathing the deceased patient is a valid question but is not priority, because the nurse needs to know the protocol to follow if an autopsy is to be done. Finding out which funeral home the deceased patient is to be transported to is valid but is not priority, because other actions must be taken before the deceased patient is transported from the hospital. Removal of lines and tubes is not a decision made by the family if an autopsy is to be done. The nurse must first check the protocol to be followed.
Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. What initial action should the nurse take?
a. Escort the cameraman to the neonatal unit while a few pictures are taken quietly.
b. Tell the cameraman where the hospital’s public relations department is located.
c. Ask the cameraman to wait while permission is obtained from the physician.
d. Ask the cameraman how the pictures are to be used in the local newspaper.
ANS: B
In some cases, information about a scientific discovery or a major medical breakthrough or an unusual situation is newsworthy. In this case, anyone seeking information needs to contact the hospital’s public relations department to ensure that invasion of privacy does not occur. It is not the nurse’s responsibility to decide independently the legality of disclosing information. The nurse does not have the right to allow the cameraman access to the neonatal unit. This would constitute invasion of privacy. The physician has no responsibility regarding this situation and cannot allow the cameraman on the unit. It is not the nurse’s responsibility to find out how the pictures are to be used. This is a task for the public relations department.
A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, “I don’t understand what the big deal is. As my instructor, you are there to protect me and make sure I don’t make mistakes.” What is the best response from the nursing instructor?
a. “You are expected to perform at the level of a professional nurse.”
b. “You are expected to perform at the level of a nursing student.”
c. “You are practicing under the license of the nurse assigned to the patient.”
d. “You are expected to perform at the level of a skilled nursing assistant.”
ANS: A
Although nursing students are not employees of the health care agency where they are having their clinical experience, they are expected to perform as professional nurses would in providing safe patient care. Different levels of standards do not apply. Nursing students, just as nurses, provide safe, complete patient care, or they don’t. No standard is used for nursing students other than that they must meet the standards of a professional nurse. The nursing instructor, not the nurse assigned to the patient, is responsible for the actions of the nursing student.
A nurse works full-time on the oncology unit at the hospital and works part-time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient’s arm and is now being sued. How will the hospital’s malpractice insurance provide coverage for this nurse?
a. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly.
b. The hospital’s malpractice insurance covers this nurse only during the time the nurse is working at the hospital.
c. As long as the nurse has never been sued before this incident, the hospital’s malpractice insurance will cover the nurse.
d. The hospital’s malpractice insurance will provide approximately 50% of the coverage the nurse will need.
ANS: B
Malpractice insurance provided by the employing institution covers nurses only while they are working within the scope of their employment at that institution. It is always wise to find out if malpractice insurance is provided by a secondary place of employment, in this case, the pharmacy, or the nurse should carry an individual malpractice policy to cover situations such as this.
A nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while she was working as a nursing assistant. What advice is best for the nursing faculty member to give to the nursing student?
a. “Just be careful when you are doing new procedures and make sure you are following directions by the nurse.”
b. “Review your procedures before you go to work, so you will be prepared to do them if you have a chance.”
c. “The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened.”
d. “You are not allowed to perform any procedures other than those in your job description even with the nurse’s permission.”
ANS: D
When nursing students work as nursing assistants or nurse’s aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse’s aide or assistant. The nursing student should always follow the directions of the nurse, unless doing so violates the institution’s guidelines or job description under which the nursing student was hired. The nursing student should be able to safely complete the procedures delegated as a nursing assistant, and reviewing those not done recently is a good idea, but it has nothing to do with the situation. This option does not address the situation that the nursing student acted outside the job description for the nursing assistant position. The focus of the discussion between the nursing faculty member and the nursing student should be on following the job description under which the nursing student is working.
The nurse calculates the medication dose for an infant on the pediatric unit and determines that the dose is twice what it should be. The pediatrician is contacted and says to administer the medication as ordered. What is the next action that the nurse should take? (Select all that apply.)
a.
Notify the nursing supervisor.
b.
Check the chain of command policy for such situations.
c.
Give the medication as ordered.
d.
Give the amount calculated to be correct.
e.
Contact the pharmacy for clarification.
ANS: A, B
Nurses follow health care providers’ orders unless they believe the orders are in error or may harm patients. Therefore, the nurse needs to assess all orders. If an order seems to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and the nurse still believe that it is inappropriate, the nurse should inform the supervising nurse or follow the established chain of command. The supervising nurse should be able to help resolve the questionable order, but only the health care provider who wrote the order or a health care provider covering for the one who wrote the order can change the order. Harm to the infant could occur if the medication dosage was too high. The nurse cannot change an order. Giving the amount calculated to be correct would not be what another nurse would do in the same situation. Although the pharmacy is an excellent resource, only the health care provider can change the order.
A nurse gives an incorrect medication to a patient without doing all of the mandatory checks, but the patient has no ill effects from the medication. What actions should the nurse take after reassessing the patient? (Select all that apply.)
a.
Notify the health care provider of the situation.
b.
Document in the patient’s medical record that an occurrence report was filed.
c.
Document in the patient’s medical record why the omission occurred.
d.
Discuss what happened with all of the other nurses and staff on the unit.
e.
Continue to monitor the patient for any untoward effects from the medication.
f.
Send an occurrence report to risk management after completing it.
ANS: A, E, F
Examples of an occurrence include an error in technique or procedure such as failing to properly identify a patient. Institutions generally have specific guidelines to direct health care providers how to complete the occurrence report. The report is confidential and separate from the medical record. The nurse is responsible for providing information in the medical record about the occurrence. It is also best for the nurse to discuss the occurrence with nursing management only. The risk management department of the institution also requires complete documentation. The fact that an occurrence report was completed is not documented in the patient’s medical record. No discussion of why the omission in procedure occurred should be documented in the patient’s medical record. Errors should be discussed only with those who need to know such as the health care provider, appropriate administrative personnel, and risk management.
The nurse hears a physician say to the charge nurse that he doesn’t want that same nurse caring for his patients because she is stupid and won’t follow his orders. The physician also writes on his patient’s medical records that the same nurse, by name, is not to care for any of his patients because of her incompetence. What component(s) of defamation has the physician committed? (Select all that apply.)
a.
Slander
b.
Invasion of privacy
c.
Libel
d.
Assault
e.
Battery
ANS: A, C
Slander occurred when the physician spoke falsely about the nurse, and libel occurred when the physician wrote false information in the chart. Both of these situations could cause problems for the nurse’s reputation. Invasion of privacy is the release of a patient’s medical information to an unauthorized person such as a member of the press, the patient’s employer, or the patient’s family. Assault is any action that places a person in apprehension of a harmful or offensive contact without consent. No actual contact is necessary. Battery is any intentional touching without consent.
A patient has just been told that he has approximately six months to live and asks about advance directives. Which statements by the nurse give the patient correct information? (Select all that apply.)
a.
“You have the right to refuse treatment at any time.”
b.
“If you want certain procedures or actions taken or not taken, and you might not be able to tell anyone at the time, you need to complete documents ahead of time that give your health care provider this information.”
c.
“You will be resuscitated at any time to allow you the longest length of survival.”
d.
“You might want to think about choosing someone who will make medical decisions for you in the event that you are unable to make your desires known.”
e.
“We will get someone who knows the state’s guidelines to assist you in setting up your living will.”
f.
“If you travel to another state, your living will should cover your wishes.”
ANS: A, B, D, E
The ethical doctrine of autonomy ensures the patient the right to refuse medical treatment. Living wills are written documents that direct treatment in accordance with a patient’s wishes in the event of a terminal illness or condition. With this legal document, the patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state. Each state providing for living wills has its own requirements for executing the health care proxy or durable power of attorney for health care (DPAHC). This is a legal document that designates a person or persons of one’s choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions based on the patient’s wishes. Cardiopulmonary resuscitation (CPR) is an emergency treatment provided without patient consent. Health care providers perform CPR on an appropriate patient unless a do not resuscitate (DNR) order has been placed in the patient’s chart. The statutes assume that all patients will be resuscitated unless a written DNR order is found in the chart. Legally competent adult patients can consent to a DNR order verbally or in writing after receiving appropriate information from the health care provider. Differences among the states have been noted regarding advance directives, so the patient should check state laws to see if a state will honor an advance directive that was originated in another state.
A patient’s condition is slowly deteriorating. What actions should the nurse take to provide the best care possible? (Select all that apply.)
a.
Allow the nursing student to receive verbal orders from the physician in the room while the nurse is in the medication area down the hall.
b.
Document the patient’s status changes in the medical record in a timely manner.
c.
Document that the health care provider has been notified of the specific patient status, including date and time that messages were left.
d.
Check the chart for frequent orders.
e.
Omit charting what the health provider’s response is to notification of the patient’s status change.
ANS: B, C
Clear, concise, and timely communication is essential whenever charting in the patient’s medical record occurs. Nursing students are not permitted to receive verbal orders. Documentation regarding communication with the health care provider must contain what was communicated by the nurse and the health care provider, orders if given, date, time, and identification of who is documenting the situation.
A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?
a.
The student nurse reviews the patient’s medical record.
b.
The student nurse reads the patient’s plan of care.
c.
The student nurse shares patient information with a friend.
d.
The student nurse documents medication administered to the patient.
ANS: C
When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated. You can review your patients’ medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient’s medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit.
A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? The nurse completed a
a.
Report.
b.
Record.
c.
Consultation.
d.
Referral.
ANS: A
Reports are oral, written, or audiotaped exchanges of information among caregivers. A patient’s record or chart is a confidential, permanent legal document consisting of information relevant to his or her health care. Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider).
Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients’ health records?
a.
The nurse determines the degree to which standards of care are met by reviewing patients’ health records.
b.
The nurse realizes that care not documented in patients’ health records still qualifies as care provided.
c.
The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients’ records.
d.
The nurse compares data in patients’ records to determine whether a new treatment had better outcomes than the standard treatment.
ANS: A
The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, “care not documented is care not provided.” The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient’s recorded findings to determine whether the new method was more effective than the standard protocol. Analysis of data from research contributes to evidence-based nursing practice and quality health care.
After providing care, a nurse charts in the patient’s record. Which entry should the nurse document?
a.
Appears restless when sitting in the chair
b.
Drank adequate amounts of water
c.
Apparently is asleep with eyes closed
d.
Skin pale and cool
ANS: D
A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.” Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as “Intake, 360 mL of water” is more accurate than “Patient drank an adequate amount of fluid.”
A nurse has provided care to a patient. Which entry should the nurse document in the patient’s record?
a.
“Patient seems to be in pain and states, ‘I feel uncomfortable.’”
b.
Status unchanged, doing well
c.
Left abdominal incision 1 inch in length without redness, drainage, or edema
d.
Patient is hard to care for and refuses all treatments and medications. Family present.
ANS: C
Use of exact measurements establishes accuracy. Charting that an abdominal wound is “5 cm in length without redness, drainage, or edema” is more descriptive than “large wound healing well.” Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as “status unchanged” or “had a good day.” It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. “Patient is hard to care for” is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, “Refuses all treatments and medications.”
A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to intervene?
a.
The new nurse uses a black ink pen to chart.
b.
The new nurse charts consecutively on every other line.
c.
The new nurse ends each entry with signature and title.
d.
The new nurse keeps the password secure.
ANS: B
Chart consecutively, line by line (not every other line); if space is left, draw a line horizontally through it, and sign your name at the end. Every other line should not be left blank. Record all entries legibly and in black ink. End each entry with your signature and title. For computer documentation, keep your password to yourself. Using black ink, ending each entry with signature and title, and keeping the password secure are all appropriate behaviors.
A nurse is charting on a patient’s record. Which action is most accurate legally?
a.
Charts legibly
b.
States the patient is belligerent
c.
Uses correction fluid to correct error
d.
Writes entry for another nurse
ANS: A
Record all entries legibly. Do not write personal opinions. Enter only objective and factual observations of patient’s behavior; quote all patient comments. For example, patient refuses to cough and deep breathe, saying, “I don’t care what you say, I will not do it.” Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself.
A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a patient enters the health care system. Which term should the nurse use to describe this system?
a.
Electronic medical record
b.
Electronic health record
c.
Electronic charting record
d.
Electronic problem record
ANS: B
A unique feature of an electronic health record (EHR) is its ability to integrate all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. Although the electronic medical record (EMR) contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably. There are no such terms as electronic charting record or electronic problem record.
A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the “I” in PIE charting?
a.
Patient went up and down stairs
b.
Deficient knowledge regarding crutches
c.
Demonstrated use of crutches
d.
Used crutches with no difficulties
ANS: C
A second progress note method is the PIE format. The narrative note includes P—Problem, I—Intervention, and E—Evaluation. The intervention is “Demonstrated use of crutches.” “Patient went up and down stairs” and “Used crutches with no difficulties” are examples of the E. “Deficient knowledge regarding crutches” is the P.
A nurse is using the source record and wants to find the daily weights. Where should the nurse look?
a.
Database
b.
Medical history and examination
c.
Progress notes
d.
Graphic sheet and flow sheet
ANS: D
In a source record, the patient’s chart has a separate section for each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record data. Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs, daily weights, and intake and output. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, the nurse’s admission history and ongoing assessment, the dietitian’s assessment, laboratory reports, radiologic test results). In the source record, the medical history and examination contain results of the initial examination performed by the physician, including findings, family history, confirmed diagnoses, and medical plan of care. In the source record, the progress notes contain an ongoing record of the patient’s progress and response to medical therapy and a review of the disease process; it often is interdisciplinary and includes documentation from health-related disciplines (e.g., health care providers, physical therapy, social work).
A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
a.
Focus charting using the DAR format.
b.
Add this data to the problem list.
c.
Document the variance in the patient’s record.
d.
Report a positive variance in the next interdisciplinary team meeting.
ANS: C
A variance occurs when the activities on the critical pathway are not completed as predicted, or the patient does not meet expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A type of narrative format charting is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness).
A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?
a.
Upon admission
b.
Right before discharge
c.
After the congestion is treated
d.
When the primary care provider writes the order
ANS: A
Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home.
A patient is being discharged home. Which information should the nurse include?
a.
Acuity level
b.
Community resources
c.
Standardized care plan
d.
Kardex
ANS: B
Discharge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions. A patient’s acuity level, usually determined by a computer program, is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance) required over a 24-hour period. Acuity level can be used for staffing and billing. Some institutions use standardized care plans to make documentation more efficient. The plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. In some settings, a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. Most Kardex forms have an activity and treatment section and a nursing care plan section, which organize information for quick reference.
A nurse developed the following discharge summary sheet. Which critical information should be added?
TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge
a. Kardex form
b. Admission nursing history
c. Mode of transportation
d. SOAP notes
ANS: C
List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style.
A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record?
a.
Nursing process form
b.
Step-by-step skills manual
c.
A list of possible procedures
d.
Reports to third party payers
ANS: D
Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record.
A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities. Which task did the nurse just complete?
a.
A focused assessment/specific body system
b.
The Resident Assessment Instrument/Minimum Data Set
c.
An admission assessment and acuity level
d.
An intake assessment form and auditing phase
ANS: B
You assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS). This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities. A focused assessment is limited to a specific body system. An admission assessment and acuity level is performed in the hospital. An intake assessment is for home health. There is no such thing as an auditing phase.
A nurse is giving a hand-off report to the oncoming nurse. Which information is critical for the nurse to report?
a.
The patient had a good day with no complaints.
b.
The family is demanding and argumentative.
c.
The patient has a new pain medication, Lortab.
d.
The family is poor and had to go on welfare.
ANS: C
Relay to staff significant changes in the way therapies are to be given (e.g., different position for pain relief, new medication). Don’t simply describe results as “good” or “poor.” Be specific. Don’t use critical comments about patient’s or family’s behavior, such as “Mrs. Wills is so demanding.” Don’t engage in idle gossip.
A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptor’s best response?
a.
“A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care.”
b.
“A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs.”
c.
“A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities.”
d.
“A change-of-shift report provides important information to caregivers and develops relationships within the health care team.”
ANS: A
Properly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care. Reimbursement costs and research priorities/opportunities are functions of the medical record. The purpose of the change-of-shift report is not to establish relationships but to ensure patient safety and continuity of care.
A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is critical for the nurse to include?
a.
Pupils equal and reactive to light
b.
The family is a “pain”
c.
Had poor results from the pain medication
d.
Sharp pain of 8 on a scale of 1 to 10
ANS: D
Elements in a change-of-shift report include identification of significant changes in measurable terms (e.g., pain scale) and by observation. Report elements do not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about the patient or family, which could possibly lead to legal charges if overheard by the patient or family. This kind of language contributes to prejudicial opinions about the patient. Don’t simply describe results as “good” or “poor.” Be specific.
Which situation will require the nurse to obtain a telephone order?
a.
As the nurse and primary care provider leave a patient’s room, the primary care provider gives the nurse an order.
b.
At 0100, a patient’s blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.
c.
At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order.
d.
A nurse reads an order correctly as written by the primary care provider in the patient’s medical record.
ANS: B
A registered nurse makes a telephone report when significant events or changes in a patient’s condition have occurred. Telephone orders and verbal orders usually occur at night or during emergencies. Because the time is 1AM (0100 military time) and the primary care provider is not present, the nurse will need to call the primary care provider for a telephone order. A verbal order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. Just reading an order that is correctly written in the chart does not require a telephone order.
A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?
a.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
b.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.
c.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
d.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.
ANS: C
The nurse receiving a TO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct. An example follows: “10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back.” VO stands for verbal order, not telephone order. The doctor’s name and read back must be included in the chart entry.
A nurse has taught the staff about informatics. Which statement indicates that the staff needs more education?
a.
If a nurse has computer competency, the nurse is competent in informatics.
b.
To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.
c.
A nurse needs to know how to acquire, critique, and apply scientific evidence from literature databases.
d.
Nursing informatics integrates nursing science, computer science, and information science to manage and communicate information in nursing practice.
ANS: A
If the staff needs more education, then an incorrect statement is made. Competence in informatics is not the same as computer competency. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. For example, you need to know how to acquire, critique, and apply scientific evidence from literature databases. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.
A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?
a.
Clinical decision support system
b.
Nursing process design
c.
Critical pathway design
d.
Computerized provider order entry system
ANS: C
One design model for Nursing Information Systems (NIS) is the protocol or critical pathway design. With this design, all health care providers use a protocol system to document the care they provide. A clinical decision support system is based on “rules” and “if-then” statements, linking information and/or producing alerts, warnings, or other information for the user. The nursing process design is the most traditional design for an NIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) is a process by which the health care provider directly enters orders for patient care into the hospital information system.
A nurse wants to reduce data entry errors on the computer system. Which behavior should the nurse implement?
a.
Use the same password all the time.
b.
Share password with only one other staff member.
c.
Print out and review computer nursing notes at home.
d.
Chart on the computer immediately after care is provided.
ANS: D
To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient’s bedside to facilitate immediate documentation of information as it is collected from a patient. A good system requires frequent and random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy (e.g., shred) anything that is printed when the information is no longer needed. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality.
Which entry will require follow-up by the nurse manager?
0800 Patient states, “Fell out of bed.” Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, “Did not pass out.” Assisted back to bed. Call bell within reach. Bed monitor on.
——————-Jane More, RN
0810 Notified primary care provider of patient’s status. New orders received. ——————-Jane More, RN
0815 Portable x-ray of L hip taken in room. States, “I feel fine.” ——————-Jane More, RN
0830 Incident report completed and placed on chart.
——————-Jane More, RN
a.
0800
b.
0810
c.
0815
d.
0830
ANS: D
Note that you do not include mention of the incident report in the patient’s medical record. Instead you document in the patient’s medical record an objective description of what happened, what you observed, and follow-up actions taken. It is important to evaluate and document the patient’s response to the error or incident. Always contact the patient’s health care provider whenever an incident happens.
A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?
a.
Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.
b.
Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, “felt better.” Finally, patient had no complaints.
c.
Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
d.
Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.
ANS: A
Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement. Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as “status unchanged” or “had a good day.” Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. “Finally, patient had no complaints” is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care.
A nurse is teaching the staff about health care reimbursement. Which information should the nurse include?
a.
Sentinel events help determine reimbursement issues for health care.
b.
Home health, long-term care, and hospital nurses’ documentation can affect reimbursement for health care.
c.
A clinical information system must be installed by 2014 to obtain health care reimbursement.
d.
HIPAA is the basis for establishing reimbursement for health care.
ANS: B
Nurses’ documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. Sentinel events do not determine reimbursement. About 60% of the worst types of medical errors, called sentinel events (involving death or severe physical/psychological injury), relate to communication problems that often arise during telephone reports. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA).
A nurse is discussing the advantages of standardized documentation forms in the nursing information system. Which advantage should the nurse describe?
a.
Varied clinical databases
b.
Reduced errors of omission
c.
Increased hospital costs
d.
More time to read charts
ANS: B
Advantages associated with the nursing information system include increased time to spend with patients (not more time to read charts); better access to information; enhanced quality of documentation; reduced errors of omission; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database.
Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)
a.
Writes the patient’s room number and date of birth on a paper for school
b.
Prints/copies material from the patient’s health record for a graded care plan
c.
Reviews assigned patient’s record and another unassigned patient’s record
d.
Reads the progress notes of assigned patient’s record
e.
Gives a change-of-shift report to the oncoming nurse about the patient
f.
Discusses patient care with the hospital volunteer
ANS: D, E
When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient’s record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Students and health care professionals may not discuss a patient’s examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient’s care. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use.
Identify the purposes of a health care record. (Select all that apply.)
a.
Communication
b.
Legal documentation
c.
Reimbursement
d.
Education
e.
Research
f.
Nursing process
ANS: A, B, C, D, E
The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.
A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)
a.
Create a password with just letters.
b.
Bypass the firewall.
c.
Use a programmed speed-dial key when faxing.
d.
Implement an automatic sign-off.
e.
Impose disciplinary actions for inappropriate access.
f.
Shred papers containing personal health information (PHI).
ANS: C, D, E, F
When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. An automatic sign-off is used in most patient care areas and other departments that handle sensitive data. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient’s name or address) must be destroyed. Most agencies have shredders or locked receptacles for shredding and later incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.
What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery?
a.
Assess the patient’s body language.
b.
Observe cardiac monitor for increased heart rate.
c.
Ask the patient to rate the level of pain.
d.
Ask the patient to describe the effect of pain on the ability to cope.
ANS: C
Pain is a subjective measure. Therefore, the best way to assess a patient’s pain is to ask the patient to rate the pain. Nonverbal communication, such as body language, is not as effective in assessing pain, especially when the patient is oriented. Heart rate sometimes increases when a patient is in pain, but this is not a symptom that is specific to pain. Pain sometimes affects a patient’s ability to cope, but assessing the effect of pain on coping assesses the patient’s ability to cope; it does not assess the patient’s pain.
A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient’s blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?
a.
“Your vitals do not show that you are having pain; can you describe your pain?”
b.
“You do not look like you are in pain.”
c.
“OK, I will go get you some narcotic pain relievers immediately.”
d.
“What would you like to try to alleviate your pain?”
ANS: D
The nurse must believe that a patient is in pain whenever the patient reports that he or she is in pain, even if the patient does not appear to be in pain. Whenever the patient reports pain, the nurse needs to collaborate with the patient to determine the best method of pain relief, whether it be medication, meditation, or repositioning. The nurse must be careful to not judge the patient based on vital signs or nonverbal communication and must not assume that the patient is seeking narcotics. The patient is a partner in pain management, so going to get narcotics to treat the pain without consulting with the patient first is not appropriate.
Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain?
a.
“Meditation controls pain by blocking pain impulses from coming through the gate.”
b.
“Meditation will help me sleep through the pain because it opens the gate.”
c.
“Meditation stops the occurrence of pain stimuli.”
d.
“Meditation alters the chemical composition of pain neuro regulators, which closes the gate.”
ANS: A
The gate theory states that pain impulses cause pain when they get through gates that are open. Pain is blocked when the gates are closed. Nonpharmacologic pain relief measures, such as meditation, work by closing the gates, which keeps pain impulses from coming through. Meditation does not open pain gates or stop pain from occurring. Meditation also does not have an effect on pain neuro regulators.
A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student’s knowledge?
a.
“Older patients often have difficulty determining what is causing their pain.”
b.
“It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient’s response to the medication.”
c.
“As adults age, their ability to perceive pain decreases.”
d.
“Patients who have dementia probably experience pain, and their pain is not always well controlled.”
ANS: B
Aging does not affect the ability to perceive pain. Sometimes older adults have difficulty interpreting their pain and determining its cause because multiple diseases and vague symptoms affect similar parts of the body. Opioids are safe to use in older adults as long as they are slowly titrated and the nurse frequently monitors the patient. Current evidence shows that patients with dementia most likely experience unrelieved pain because their pain is difficult to assess.
The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?
a.
Neurological factors
b.
Competency of the surgeon
c.
Meaning of pain
d.
Postoperative support personnel
ANS: C
The patient’s perception of pain is influenced by psychological factors, such as anxiety and coping, which in turn influence the patient’s experience of pain. Each patient’s experience is different. The degree and quality of pain perceived by a patient are related to the meaning of the pain. Neurological factors can interrupt or influence pain perception, but neither of these patients is experiencing alterations in neurological function. The knowledge, attitudes, and beliefs of nurses, physicians, and other health care personnel about pain affect pain management but do not necessarily influence a patient’s pain perceptions.
The nurse anticipates administering an opioid fentanyl patch to which patient?
a.
A 15-year-old adolescent with a broken femur
b.
A 30-year-old adult with cellulitis
c.
A 50-year-old patient with prostate cancer
d.
An 80-year-old patient with a broken hip
ANS: C
A fentanyl patch is an extended-relief opioid that provides pain relief for 24 hours a day. This is ideal for patients who have chronic severe pain, such as those who have cancer. The other patients are expected to experience acute pain. Therefore, they will most likely benefit from oral or IV opioids for short-term pain relief.
What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia?
a.
Keeping the reversal agent in a syringe in the patient’s bedside table
b.
Applying a gauze dressing to the epidural catheter insertion site
c.
Labeling the tubing that leads to the epidural catheter
d.
Asking the nursing assistive personnel to check on the patient at least once every 2 hours
ANS: C
To reduce the accidental administration of IV medications into the epidural catheter, the tubing that leads to the epidural catheter needs to be labeled clearly. Medications used to reverse the action of the anesthetic medication need to be kept in a secured location, not in the patient’s room in an unsecured location. The epidural insertion site needs to be covered by a clear occlusive dressing to prevent infection and allow the nurse to assess the site. Patients receiving epidural anesthesia need to be monitored every 15 minutes until stabilized and then at least hourly.
A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?
a.
Relaxation and guided imagery
b.
Transcutaneous electrical nerve stimulation (TENS)
c.
Herbal supplements with analgesic effects
d.
Pudendal block
ANS: A
Some cultures prefer nonpharmacological measures for pain control. In the case of a patient in labor, relaxation with guided imagery is often an effective supplement for pain management because it provides women with a sense of control over their pain. Relaxation and guided imagery can be used during any phase of health or illness. TENS units are typically used to manage postsurgical and procedural pain. Herbal supplements need to be evaluated for safety during pregnancy. Additionally, some patients consider herbal supplements to be another form of medication, and they are not typically used to control acute pain. A pudendal block is a type of regional anesthesia; use of it does not respect the patient’s wishes for nonpharmacological pain control.
Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective?
a.
“This is the only pain medication I will need to be on.”
b.
“I can administer the pain medication as frequently as I need to”
c.
“I feel less anxiety about the possibility of overdosing.”
d.
“I will need the nurse to notify me when it is time for another dose.”
ANS: C
A PCA is a device that allows the patient to determine the level of pain relief delivered, reducing the risk of oversedation. Its use often eases anxiety because the patient is not reliant on the nurse for pain relief. Other medications, such as oral analgesics, can be given in addition to the PCA machine. The PCA does have a time limit to prevent overdose, but the patient can lengthen the amount of time between doses. One benefit of PCA is that the patient does not need to rely on the nurse to administer pain medication; the patient determines when to take the medication.
A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management?
a.
“To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain.”
b.
“You should take your medication after you walk to make sure you do not fall while you are walking.”
c.
“We should work together to create a regular schedule of medications that does not allow for breakthrough pain.”
d.
“You need to take oral pain medications when you experience severe pain.”
ANS: C
The best way to manage pain is to develop a schedule of medications that are given around the clock to prevent breakthrough pain. The nurse should not wait until pain is experienced because it takes medications 10-30 minutes to begin to relieve pain. The nurse administers pain medications before painful activities, such as walking, and administers intravenous medications when a patient is having severe pain.
A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient’s behavior and response to surgery?
a.
The surgery successfully cured the patient’s pain.
b.
The patient’s culture is possibly influencing the patient’s experience of pain.
c.
The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain.
d.
The nurse is allowing personal beliefs about pain to influence pain management at this time.
ANS: B
A patient’s culture often influences the patient’s expression of pain. In this case, the patient has just had surgery, and the nurse knows that this surgical procedure usually causes patients to experience pain. It is important at this time for the nurse to examine cultural and ethnic factors that are possibly affecting the patient’s lack of expression of pain at this time. Even if surgery corrects neurological factors that create chronic pain, surgery causes pain in the acute period. Urinary retention usually creates pain and does not mask surgical pain. The nurse is not allowing personal beliefs to influence pain management because the nurse is attempting to determine the reason why the patient is not verbalizing the experience of pain.
A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide?
a.
“Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer.”
b.
“Narcotics can be addictive, so do not take them unless you are in severe pain.”
c.
“You need to drink plenty of fluids and eat a diet high in fiber.”
d.
“As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections.”
ANS: C
A common side effect of opioid analgesics is constipation. Therefore, the nurse encourages the patient to drink fluids and eat fiber to prevent constipation. Although medications can be irritating to the stomach, eating a diet high in fat does not prevent gastric ulcers. To best manage pain, the patient needs to take pain medication before painful procedures or activities or before pain becomes severe. As the patient’s pain gets better, the strength of the medications will decrease. IM, IV, and topical analgesics are used for more severe and chronic pain.
A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider?
a.
Frequently reassesses the patient’s pain scores
b.
Reassures the patient that the provider will come to the emergency department soon
c.
Softly plays music that the patient finds relaxing
d.
Teaches the patient how to do yoga
ANS: C
The appropriate nonpharmacological pain management intervention is to quietly play music that the patient finds relaxing. Music diverts a person’s attention away from pain and creates relaxation. Reassessing the patient’s pain scores is done during evaluation. Building the patient’s expectation of the provider’s arrival does not address the patient’s pain. Although yoga promotes relaxation, nurses teach relaxation techniques only when a patient is not experiencing acute pain. Because the patient is having acute pain, this is not an appropriate time to provide patient teaching.
A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction?
a.
“Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet.”
b.
“Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy.”
c.
“Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet.”
d.
“You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot.”
ANS: D
This patient is losing the ability to feel pain owing to peripheral neuropathy. The patient will no longer have protective reflexes to prevent injury to the feet. Wearing shoes prevents the patient from injuring the foot because they protect the feet. Shoes do not block pain perception, nor do they help people adapt to pain. Shoes are not a form of nonpharmacological pain relief. Wearing shoes will not have an effect on opening or closing the pain gates.
A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, “The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most.” What type of pain does the nurse document that the patient is having at this time?
a.
Superficial pain
b.
Idiopathic pain
c.
Chronic pain
d.
Visceral pain
ANS: D
Visceral pain comes from visceral organs, such as those from the gastrointestinal tract. Visceral pain is diffuse and radiates in several directions. Superficial pain has a short duration and is usually a sharp pain. Pain of an unknown cause is called idiopathic pain. Chronic pain lasts longer than 6 months.
A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA?
a.
The patient is sleeping and is difficult to arouse.
b.
The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.
c.
Sufficient medication is left in the PCA syringe.
d.
The patient presses the control button to deliver pain medication.
ANS: B
The effectiveness of pain relief measures is determined by the patient. If the patient is satisfied with the amount of pain relief, then pain measures are effective. A patient who is sleeping and is difficult to arouse is possibly oversedated; the nurse needs to assess this patient further. The amount of medication left in the PCA syringe does not indicate whether pain management is effective. Pressing the button shows that the patient knows how to use the PCA but does not evaluate pain management.
The nurse recognizes that which of the following is a modifiable contributor to a patient’s perception of pain?
a.
Age and gender
b.
Anxiety and fear
c.
Culture
d.
Previous pain experience
ANS: B
The nurse can take measures to ease the patient’s anxiety and fear related to pain. Age, gender, culture, and previous pain experience are all nonmodifiable factors that the nurse can help the patient to understand, but the nurse cannot alter them.
The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient’s pain during dressing changes?
a.
The patient’s need for analgesic medication decreases during the dressing changes.
b.
The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
c.
The patient’s facial expressions are stoic during the procedure.
d.
The patient can tolerate more pain, so dressing changes can be performed more frequently.
ANS: A
The purpose of guided imagery is to allow the patient to alter the perception of pain. Guided imagery works in conjunction with analgesic medications, potentiating their effects. If the patient needs less pain medication during dressing changes, then guided imagery is helping to manage the patient’s pain. A rating of 6 on a 0 to 10 scale indicates that the patient is having moderate pain and shows that this patient is not experiencing pain relief at this time. A person who is stoic is not showing feelings, which makes it difficult to know whether or not the patient is experiencing pain. The ability to change dressings more frequently is not a way to evaluate the effectiveness of guided imagery.
