Nokea
To what does objective data refer when assessing a patient?
- A. the provider's observed data
- B. All of the answers are correct
- C. the patient's perception of provided data
- D. the patient's request for information
Correct Answer: A
Rationale: Objective data (A) includes measurable findings by the provider, like vital signs. C and D are subjective, and B is incorrect as only A is accurate.
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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.
JCAHO regulates standards of care to:
- A. ensure subjective documentation
- B. make sure that all nurses use the same charting system
- C. ensure quality patient care
- D. make sure insurance companies get paid correctly
Correct Answer: C
Rationale: JCAHO (C) focuses on improving patient safety and care quality through standards. A is incorrect as objective documentation is emphasized. B is incorrect as charting systems vary. D is incorrect as reimbursement is not JCAHO's focus.
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.
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.
When documenting events in a patient's chart, the nurse should chart:
- A. the specific time of all sudden changes in the patient's condition
- B. the period the shift covers
- C. every 2 hours
- D. every hour on the hour
Correct Answer: A
Rationale: Charting sudden changes with specific times (A) ensures accuracy and supports care decisions. B, C, and D are less precise or unnecessary.