Nokea
Which of the following is an example of good charting?
- A. No complaints of pain or discomfort.'
- B. The patient states, 'It feels like a knife stabbing me.'
- C. Lump diminished.'
- D. Patient's condition much better today than yesterday.'
Correct Answer: B
Rationale: Quoting the patient's exact words (B) is precise and clear. A lacks verification, C is vague, and D lacks measurable detail.
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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.
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.
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.
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.
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.