Nokea
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.
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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.
Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis
- A. the patient is vulnerable to develop the problem
- B. there is no evidence of defining characteristics
- C. a condition is currently present
- D. it is written as a two-part statement
Correct Answer: C
Rationale: An actual nursing diagnosis (C) indicates a current condition with observable signs. A risk diagnosis (A) suggests potential for a problem. B is incorrect as actual diagnoses require evidence. D is incorrect as actual diagnoses use a three-part statement.
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.
On what form/forms should the nurse chart when administering a narcotic?
- A. Physician's Order Sheet
- B. Narcotic Administration Sheet
- C. Care Plan
- D. MAR and Narcotic Administration Sheet
Correct Answer: D
Rationale: Narcotics are documented on both the MAR (Medication Administration Record) (D) for all medications and the Narcotic Administration Sheet for controlled substances to ensure tracking and compliance. A, B alone, and C are incorrect.
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.