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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.
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One benefit of computerized charting is that:
- A. it increases cost
- B. it promotes individualization of the medical record
- C. it improves legibility
- D. it minimizes the number of forms to be completed
Correct Answer: C
Rationale: Computerized charting (C) improves legibility, reducing errors from illegible handwriting. A, B, and D are incorrect or less accurate benefits.
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.
In which step of the nursing process do nurses look at outcomes?
- A. Evaluation
- B. Assessment
- C. Implementation
- D. Planning
Correct Answer: A
Rationale: Evaluation (A) is where nurses assess whether outcomes and goals were met. Assessment (B) collects data, Implementation (C) executes interventions, and Planning (D) sets goals.
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 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.