Nokea
Patient with dyspnea
The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:
- A. implementation
- B. evaluation
- C. planning
- D. assessment
Correct Answer: C
Rationale: Planning (C) involves selecting interventions for patient needs, like dyspnea. A, B, and D represent other phases.
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Select the type of assessment which is performed continuously throughout nurse-patient contact:
- A. focused
- B. body systems
- C. subjective
- D. complete
Correct Answer: A
Rationale: Focused assessments (A) are ongoing, targeting specific issues like pain or breathing during contact. Body systems (B), subjective (C), and complete (D) assessments are not continuous.
Identify the two primary methods used to collect data:
- A. interview and physical examination
- B. review of the doctor's orders and the Kardex
- C. written report by patient and family
- D. review of the chart and the nurse's notes
Correct Answer: A
Rationale: Interview and physical examination (A) collect subjective and objective data directly. B, C, and D are secondary or supportive methods.
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 appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated
The nurse documents in the patient record, '0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.' The most significant statement about the documentation is that it is:
- A. unacceptable because it is vague subjective data without supportive data
- B. good because it shows immediate response to the problem
- C. inadequate because the time of physician notification is not listed
- D. acceptable because it includes assessment, intervention and evaluation
Correct Answer: D
Rationale: The documentation (D) includes assessment (pain, vital signs), intervention (analgesic), and evaluation (relief), making it complete. A, B, and C overlook its comprehensive nature.
A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)
- A. Wait until the end of the shift to document
- B. Cover errors with correction fluid, and write in the correct information
- C. Use as many abbreviations as possible to save space
- D. Document objective data, leaving out opinions
- E. The date and time should be included with each entry
Correct Answer: D,E
Rationale: D: Documentation must be objective (e.g., 'grimaced when moving') to avoid bias. E: Including date and time ensures a clear timeline for legal and care continuity. A is incorrect because timely documentation prevents errors. B is incorrect as errors should be corrected with a single line and initials. C is incorrect because only approved abbreviations should be used to avoid confusion.