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A nurse is charting on a patient’s record. Whichaction will the nurse take that is accurate legally?
- A. Charts legibly
- B. States the patient is belligerent
- C. Writes entry for another nurse
- D. Uses correction fluid to correct error
Correct Answer: A
Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues.
Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient. Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences. Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.
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Which piece of data will the nurse use for “B” when using SBAR?
- A. Having chest pain
- B. Pulse rate of 108
- C. History of angina
- D. Oxygen is needed
Correct Answer: C
Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.
Which behaviors indicate the student nurse hasa good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Selectall 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. Gives a change-of-shift report to the oncoming nurse about the patient
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
- Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals.
- A: Writing the patient’s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals.
- B: Printing/copying material from the patient’s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization.
- C: Reviewing assigned patient’s record and another unassigned patient’s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.
The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patients risk of hypercalcemia?
- A. Stool softeners are contraindicated.
- B. Laxatives should be taken daily.
- C. Consume 2 to 4 L of fluid daily.
- D. Restrict calcium intake.
Correct Answer: C
Rationale: Rationale: Option C is correct because adequate hydration helps prevent hypercalcemia by promoting the excretion of excess calcium in the urine. This reduces the risk of calcium buildup in the blood. Consuming 2 to 4 liters of fluid daily ensures proper hydration, which is crucial for patients at risk for hypercalcemia. Stool softeners (Option A) are not contraindicated and can help prevent constipation, which may be a side effect of some cancer treatments. Laxatives (Option B) should not be taken daily as they can lead to dehydration and electrolyte imbalances. Restricting calcium intake (Option D) is not the primary intervention for preventing hypercalcemia; rather, maintaining adequate hydration is key.
The organization of a patients care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice?
- A. It is based on the participation of clinicians without a team leader.
- B. It is based on clinicians of varied backgrounds integrating their separate plans of care.
- C. It is based on communication and cooperation between disciplines.
- D. It is based on medical expertise and patient preference with the support of nursing.
Correct Answer: B
Rationale: Interdisciplinary collaboration involves clinicians from different backgrounds integrating their separate plans of care, ensuring a holistic approach to patient care. This fosters a comprehensive understanding of the patient's needs and individualized care. In contrast, multidisciplinary practice involves clinicians working independently without integrating their plans, potentially leading to fragmented care.
Choice A is incorrect as interdisciplinary collaboration does have a team leader to coordinate and facilitate communication among team members.
Choice C is incorrect because while communication and cooperation are essential in interdisciplinary collaboration, the key distinction is the integration of different perspectives and plans of care.
Choice D is incorrect as interdisciplinary collaboration goes beyond just medical expertise and patient preference, involving professionals from various disciplines working together to address all aspects of patient care.
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?
- A. Pruritis (itching)
- B. Nausea and vomiting
- C. Altered glucose metabolism
- D. Confusion
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapy commonly causes gastrointestinal side effects, such as nausea and vomiting, due to its impact on rapidly dividing cells in the digestive tract. This adverse effect can significantly impact a patient's quality of life and adherence to treatment. Pruritis (A), itching, is less common and usually not a primary side effect of chemotherapy. Altered glucose metabolism (C) is a potential effect of some chemotherapeutic agents but is not the most common adverse effect. Confusion (D) is not typically associated with chemotherapy and is more commonly seen with other medications or medical conditions.