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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.
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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.
Select the proper order of the phases of the Nursing Process:
- A. Evaluation, planning, assessment, implementation
- B. Assessment, planning, implementation, evaluation
- C. Implementation, assessment, planning, evaluation
- D. Planning, evaluation, assessment, implementation
Correct Answer: B
Rationale: The nursing process follows a logical sequence: Assessment (data collection), Planning (developing goals and interventions), Implementation (executing the plan), and Evaluation (assessing effectiveness). Only option B lists this correct order.
Patient reporting moderate to severe pain
A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (select all that apply)
- A. Repeat the details of the prescription back to the provider
- B. Record the reason for the call made to the provider and the results of the call in the Nurses Notes
- C. Tell the charge nurse that the provider has prescribed morphine by telephone
- D. Refuse to accept the verbal prescription because this is not an emergency
Correct Answer: A,B
Rationale: A: Repeating the prescription ensures accuracy via read-back verification. B: Documenting the call's reason and outcome is essential for legal records. C is good practice but not required, and D is incorrect as verbal orders can be accepted with proper protocol.
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.
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.