Nokea
Patient is confined to bed rest
The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?
- A. as difficult to maintain
- B. as a risk factor
- C. as a nursing responsibility
- D. as contributing to the patient's recovery
Correct Answer: B
Rationale: Bed rest (B) is a risk factor for complications like pressure ulcers or DVT, which should be noted in the care plan. A is subjective, C is an intervention, and D is incomplete as bed rest can hinder recovery if prolonged.
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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.
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.
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.
Patient with a urinary tract infection
The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date it is determined that a/an:
- A. omission exists
- B. failure exists
- C. variance exists
- D. error exists
Correct Answer: C
Rationale: A variance (C) occurs when outcomes deviate from the critical pathway's timeline, indicating a need for reassessment. A, B, and D are less precise terms.
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.