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A nurse has access to computerized standardized plans of care. After printing one for a patient, what must be done next?
- A. Date it and put it in the patients record.
- B. Sign it and put it in the Kardex.
- C. Individualize it to the specific patient.
- D. Use it as printed, based on common needs.
Correct Answer: C
Rationale: Standardized care plans must be tailored to the patient's unique needs to ensure appropriate and effective care.
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A student has reviewed a patients chart before beginning assigned care. Which of the following actions violates patient confidentiality?
- A. writing the patients name on the student care plan
- B. providing the instructor with plans for care
- C. discussing the medications with a unit nurse
- D. providing information to the physician about laboratory data
Correct Answer: A
Rationale: Including the patient's name on a student care plan can expose confidential information if not properly secured, violating confidentiality.
Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?
- A. Alice J, RN
- B. A. Jones, RN
- C. Alice Jones
- D. AJRN
Correct Answer: B
Rationale: The standard format for signing documentation is the nurse's initial, last name, and credentials (e.g., A. Jones, RN), ensuring clarity and professionalism.
What is the nurses best defense if a patient alleges nursing negligence?
- A. testimony of other nurses
- B. testimony of expert witnesses
- C. patients record
- D. patients family
Correct Answer: C
Rationale: The patient's record is the most objective and reliable evidence of the care provided, serving as the nurse's best defense against allegations of negligence.
A physicians order reads up ad lib. What does this mean in terms of patient activity?
- A. may walk twice a day
- B. may be up as desired
- C. may only go to the bathroom
- D. must remain on bed rest
Correct Answer: B
Rationale: Up ad lib' means the patient may be up and active as desired, without restrictions.
A nurse is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?
- A. PIE system
- B. minimum data set
- C. OASIS
- D. charting by exception
Correct Answer: B
Rationale: The minimum data set is a standardized tool used in Medicare-certified facilities for comprehensive resident assessment and RAI development.