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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.
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Who should document care in the patient record?
- A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.
- B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.
- C. All staff members should document all of the care that they have provided.
- D. All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.
Correct Answer: C
Rationale: All staff (C) must document their own care for accuracy and accountability. A, B, and D incorrectly assign documentation responsibilities.
What is the major concern when using a computer for documentation?
- A. confidentiality
- B. adequate forms for documentation
- C. incorrect information
- D. of the answers are correct
Correct Answer: A
Rationale: Confidentiality (A) is the primary concern due to risks of unauthorized access or breaches. B and C are managed by system design, and D is incorrect.
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 reporting moderate to severe pain
A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (select all that apply)
- A. Repeat the details of the prescription back to the provider
- B. Record the reason for the call made to the provider and the results of the call in the Nurses Notes
- C. Tell the charge nurse that the provider has prescribed morphine by telephone
- D. Refuse to accept the verbal prescription because this is not an emergency
Correct Answer: A,B
Rationale: A: Repeating the prescription ensures accuracy via read-back verification. B: Documenting the call's reason and outcome is essential for legal records. C is good practice but not required, and D is incorrect as verbal orders can be accepted with proper protocol.
Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:
- A. CNA
- B. Technician
- C. RN
- D. LPN/LVN
Correct Answer: C
Rationale: The RN (C) is responsible for analyzing data and formulating nursing diagnoses, as it requires critical thinking within their scope of practice. CNAs (A) and Technicians (B) assist with care but do not diagnose. LPNs/LVNs (D) collect data but do not formulate diagnoses.