Nokea
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.
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Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:
- A. patient's nursing problem
- B. interventions carried out to meet the patient's needs
- C. patient's medical problem
- D. the patient's response to the intervention carried out
Correct Answer: B
Rationale: Documenting interventions, time, and signature (B) records actions taken to address patient needs, ensuring accountability. A and C relate to diagnoses, and D focuses on outcomes, not interventions.
Patient with a nursing diagnosis of airway clearance, ineffective
The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:
- A. oxygen will be continued
- B. the patient's coughing frequency will increase
- C. cyanosis may be present
- D. within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea
Correct Answer: D
Rationale: The desired outcome for ineffective airway clearance (D) is measurable improvement, like no dyspnea within 24 hours. A is an intervention, B does not ensure clearance, and C indicates worsening.
Patient walks with a limp; Patient reports pain level as 3 on a scale of 1 to 10; Coughed up 5 mL yellow sputum; Headache in frontal area
The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)
- A. Assistive personnel reports the patient walks with a limp
- B. Patient reports pain level as 3 on a scale of 1 to 10
- C. Heart rate 72 beats per minute
- D. Respiratory rate 22 per minute with even unlabored respirations
- E. Coughed up 5 mL yellow sputum
- F. Headache in frontal area
Correct Answer: C,D,E
Rationale: C: Heart rate is measured, making it objective. D: Respiratory rate is observed and quantified, thus objective. E: Sputum volume and color are observable, hence objective. A is secondhand, B and F are subjective patient reports.
To what does objective data refer when assessing a patient?
- A. the provider's observed data
- B. All of the answers are correct
- C. the patient's perception of provided data
- D. the patient's request for information
Correct Answer: A
Rationale: Objective data (A) includes measurable findings by the provider, like vital signs. C and D are subjective, and B is incorrect as only A is accurate.
Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:
- A. ethically can look at a friend's chart to see the diagnosis
- B. shares information from a chart to protect a friend
- C. knows that only the Patient's Bill of Rights advocates confidentiality
- D. reads charts only for professional reasons
Correct Answer: D
Rationale: Nurses must access records only for professional reasons (D) to comply with HIPAA. A and B violate confidentiality, and C is incorrect as multiple laws protect privacy.