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Patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation
During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:
- A. signs of fluid overload
- B. symptoms
- C. data clustering
- D. urinary retention
Correct Answer: C
Rationale: Grouping signs like flushed skin and fever (C) is data clustering, suggesting dehydration or infection. Fluid overload (A) shows edema, symptoms (B) are subjective, and urinary retention (D) involves bladder issues.
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Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)
- A. Incident reports must be recorded in the nurse's notes
- B. Institutions are only reimbursed for patient care that is documented
- C. Document only when not successful
- D. The patient record is a complete picture of individualized problems, treatments and responses to treatments
Correct Answer: B,D
Rationale: B: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as it proves care was provided. D: The patient record provides a comprehensive view of the patient's problems, treatments, and responses, ensuring continuity of care. A is incorrect because incident reports are separate from the medical record to maintain patient safety internally. C is incorrect because documentation should include both successful and unsuccessful interventions for completeness.
Patient with edema has a problem of fluid overload
A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:
- A. use a Nursing Diagnosis from a source other than NANDA-I
- B. limit the number of interventions
- C. select interventions which will be easy to implement
- D. involve the patient in the process
Correct Answer: D
Rationale: Involving the patient in the care plan (D) ensures better adherence and personalization, which is critical for effective fluid reduction. A is incorrect because NANDA-I provides standardized diagnoses for accuracy. B is incorrect as interventions should be sufficient, not arbitrarily limited. C is incorrect because interventions should be effective, not merely easy.
Which of the following statements is correct about abbreviations?
- A. Every facility should have an approved abbreviations list.
- B. Creating abbreviations saves time for the person reading the chart.
- C. Writing out questionable abbreviations could make a jury think you're hiding something
- D. Abbreviating drug name and dosages helps reduce medication errors.
Correct Answer: A
Rationale: Approved abbreviation lists (A) ensure clarity and prevent errors. B, C, and D are incorrect as unapproved abbreviations cause confusion and risks.
Clarify the primary purpose of nursing orders:
- A. to clarify nursing principles
- B. to resolve the patient's problems
- C. to support physician's orders
- D. to provide broad, general statements
Correct Answer: B
Rationale: Nursing orders (B) aim to address patient problems directly through targeted interventions. A, C, and D do not capture this primary focus.
Patient provided subjective data of intermittent chest pain upon exertion
Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:
- A. a head-to-toe assessment
- B. subjective data collection
- C. objective data collection
- D. Maslow's Hierarchy of Needs
Correct Answer: A
Rationale: A head-to-toe assessment (A) organizes a complete exam systematically. B and C are data types, not approaches, and D prioritizes needs, not physical exams.