Nokea
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.
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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 was administered a stat insulin dose
The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:
- A. the insulin was administered based per the nurse's testimony
- B. none of the answers are correct
- C. the insulin was administered based on the witness testimony
- D. the insulin was not administered because it was not charted
Correct Answer: D
Rationale: Legally, 'if it wasn't documented, it wasn't done' (D). Without MAR documentation, the insulin administration cannot be verified, despite testimony (A, C). B is incorrect as D is accurate.
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.
Clarify the primary purpose of nursing orders:
- A. to clarify nursing principles
- B. to resolve the patient's problems
- C. to support physician's orders
- D. to provide broad, general statements
Correct Answer: B
Rationale: Nursing orders (B) aim to address patient problems directly through targeted interventions. A, C, and D do not capture this primary focus.
Patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated
The nurse documents in the patient record, '0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.' The most significant statement about the documentation is that it is:
- A. unacceptable because it is vague subjective data without supportive data
- B. good because it shows immediate response to the problem
- C. inadequate because the time of physician notification is not listed
- D. acceptable because it includes assessment, intervention and evaluation
Correct Answer: D
Rationale: The documentation (D) includes assessment (pain, vital signs), intervention (analgesic), and evaluation (relief), making it complete. A, B, and C overlook its comprehensive nature.