Nokea
What is the major concern when using a computer for documentation?
- A. confidentiality
- B. adequate forms for documentation
- C. incorrect information
- D. of the answers are correct
Correct Answer: A
Rationale: Confidentiality (A) is the primary concern due to risks of unauthorized access or breaches. B and C are managed by system design, and D is incorrect.
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Patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg
Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?
- A. pain
- B. skin integrity
- C. fluid volume
- D. knowledge deficit
Correct Answer: A
Rationale: Pain (A) is the immediate need due to severe discomfort, requiring urgent management. Skin integrity (B), fluid volume (C), and knowledge deficit (D) are secondary.
Patient with edema has a problem of fluid overload
The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)
- A. Teaching deep breathing and relaxation techniques as needed
- B. Inserting a nasogastric tube (NG) to relieve gastric distention
- C. Placing the nurse call button within reach at all times
- D. Giving hand massages daily
- E. Repositioning the patient every 2 hours to reduce pressure injury risk
- F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed
Correct Answer: A,C,D,E
Rationale: A: Teaching non-pharmacological techniques is within a nurse's scope without a physician's order. C: Ensuring the call button is accessible promotes safety independently. D: Hand massages are a comfort measure nurses can provide independently. E: Repositioning prevents pressure injuries and is an independent action. B requires a physician's order, and F involves medication administration, which is dependent.
Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:
- A. CNA
- B. Technician
- C. RN
- D. LPN/LVN
Correct Answer: C
Rationale: The RN (C) is responsible for analyzing data and formulating nursing diagnoses, as it requires critical thinking within their scope of practice. CNAs (A) and Technicians (B) assist with care but do not diagnose. LPNs/LVNs (D) collect data but do not formulate diagnoses.
When using the SOAP method of charting, S stands for subjective data which means:
- A. patient provided data
- B. all of the answers are correct
- C. observed data
- D. measured data
Correct Answer: A
Rationale: Subjective data (A) includes patient-reported information like pain or symptoms. Observed (C) and measured (D) data are objective, and B is incorrect as only A is accurate.
Patient provided subjective data of intermittent chest pain upon exertion
Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:
- A. a head-to-toe assessment
- B. subjective data collection
- C. objective data collection
- D. Maslow's Hierarchy of Needs
Correct Answer: A
Rationale: A head-to-toe assessment (A) organizes a complete exam systematically. B and C are data types, not approaches, and D prioritizes needs, not physical exams.