Nokea
The primary source of assessment information is:
- A. the patient's friends
- B. past medical records
- C. the patient's record
- D. the patient
Correct Answer: D
Rationale: The patient (D) is the primary source for assessment data, providing real-time information on symptoms and concerns. Friends (A) and records (B, C) are secondary sources and may not reflect current status.
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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.
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.
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.
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.
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.