Term
A manager is reviewing the nurses' notes in a client's medical record. She finds the following entry, “Client is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions should the manager give to the staff nurse who entered the note?
1. Avoid rushing when charting an entry
2. Use correction fluid to remove the entry.
3. Draw a single line through the statement and initial it.
4. Enter only objective and factual information about the client. |
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Definition
| 4. Enter only objective and factual information about the client. |
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Term
A client tells the nurse, “I have stomach cramps and feel nauseous.” This is an example of what type of data?
1. Objective
2. Historical
3. Subjective
4. Assessment |
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Definition
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Term
As you enter the client's room, you notice he is anxious to say something. He quickly states, “I do not know what is going on; I cannot get an explanation from my doctor about the results of my test. I want something done about this.” Which of the following is most appropriate documentation of the client's emotional status?
1. The client has a defiant attitude.
2. The client appears to be upset with his physician.
3. The client is demanding and complains frequently.
4. The client stated that he felt frustrated by the lack of information he received regarding his diagnostic tests. |
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Definition
| 4. The client stated that he felt frustrated by the lack of information he received regarding his diagnostic tests. |
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Term
A primary benefit of HIPAA regulations is to:
1. Allow access of the medical record to all hospital staff
2. Limit what information must be documented in the client's record
3. Provide clients with greater control over personal health care information
4. Enable health care institutions to release any client-related information with a general client authorization |
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Definition
| 3. Provide clients with greater control over personal health care information |
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Term
Clients frequently request copies of their medical records. The nurse understands:
1. Only the families may read the records
2. They have the right to read those records
3. They are not allowed to read those records
4. Only the health care workers have access to the records |
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Definition
| 2. They have the right to read those records |
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Term
Accurate entries are an important characteristic of good documentation. Which of the following charting entries is most accurate in the way it is written?
1. Client up, out of bed, walked down hallway with assistance, tolerated well.
2. Client up, out of bed, walked 50 feet and back down hallway, tolerated well.
3. Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse.
4. Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse, HR 88 and regular before exercise, 94 and regular following exercise. |
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Definition
| 4. Client up, out of bed, walked 50 feet and back down hallway with assistance from nurse, HR 88 and regular before exercise, 94 and regular following exercise |
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Term
Match the correct entry with the appropriate SOAP category.
S
O
A
P
Repositioned client on right side. Encouraged client to use PCA device.
The pain increases every time I try to turn on my left side.
Acute pain related to tissue injury from surgical incision.
Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. |
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Definition
Repositioned client on right side. Encouraged client to use PCA device. (P)
The pain increases every time I try to turn on my left side. (S)
Acute pain related to tissue injury from surgical incision. (A)
Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. (O) |
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Term
On the nursing unit at Stevens Health Center a nurse is able to access a client's medical record and review the education that nurses provided the client during an initial hospitalization and three subsequent clinic visits. This type of record system is an example of:
1. Information technology
2. Electronic health record
3. Personal health information
4. Administrative information system |
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Definition
| 2. Electronic health record |
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Term
If the infectious disease can be transmitted directly from one person to another, it is a:
1. Susceptible host
2. Communicable disease
3. Portal of entry to a host
4. Portal of exit from the reservoir |
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Definition
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Term
The viruses that cause hepatitis B or C live in which of the following reservoirs?
1. Blood
2. The urinary tract
3. The respiratory tract
4. The reproductive tract |
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Definition
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Term
The interval when a client manifests signs and symptoms specific to a type of infection is the:
1. Illness stage
2. Convalescence
3. Prodromal stage
4. Incubation period |
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Definition
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Term
The most effective way to break the chain of infection is by:
1. Hand hygiene
2. Wearing gloves
3. Placing clients in isolation
4. Providing private rooms for clients |
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Definition
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Term
After coming in contact with infected clients, and after handling contaminated equipment or organic material, visitors are encouraged to:
1. Wear gloves before eating or handling food
2. Use a private room to talk with family members
3. Leave the facility to prevent contamination of others
4. Perform hand hygiene before eating or handling food |
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Definition
| 4. Perform hand hygiene before eating or handling food |
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Term
A client is isolated for pulmonary tuberculosis. The nurse notes the client seems to be angry, but he knows this is a normal response to isolation. The best intervention is to:
1. Provide a dark, quiet room to calm the client
2. Reduce the level of precautions to keep the client from becoming angry
3. Explain the reasons for isolation procedures and provide meaningful stimulation
4. Limit family and other caregiver visits to reduce the risk of spreading the infection |
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Definition
| 3. Explain the reasons for isolation procedures and provide meaningful stimulation |
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Term
A gown should be worn when:
1. The client's hygiene is poor
2. The nurse is assisting with medication administration
3. The client has acquired immunodeficiency syndrome (AIDS) or hepatitis
4. Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform |
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Definition
| 4. Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform |
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Term
The nurse has redressed a client's wound and now plans to administer a medication to the client. It is important to:
1. Leave the gloves on to administer the medication
2. Remove gloves and perform hand hygiene before leaving the room
3. Remove gloves and perform hand hygiene before administering the medication
4. Leave the medication on the bedside table to avoid having to remove gloves before leaving the client's room |
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Definition
| 3. Remove gloves and perform hand hygiene before administering the medication |
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Term
When a nurse is performing surgical hand asepsis, the nurse must keep hands:
1. Below elbows
2. Above elbows
3. At a 45-degree angle
4. In a comfortable position |
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Definition
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Term
To sterilize surgical instruments, parenteral solutions, and surgical dressings:
1. An autoclave is used
2. Soap and water is used
3. Ethylene oxide gas is used
4. Chemicals are used for disinfection |
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Definition
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Term
The physiological changes that occur during the aging process increase the older client's risk for:
1. Poisoning
2. Alcoholism
3. Falls and burns
4. Medication errors |
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Definition
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Term
You discover an electrical fire in a client's room. Your first action would be to:
1. Activate the fire alarm
2. Confine the fire by closing all doors and windows
3. Evacuate any clients or visitors in immediate danger
4. Extinguish the fire by using the nearest fire extinguisher |
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Definition
| 3. Evacuate any clients or visitors in immediate danger |
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Term
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction you can give to this parent?
1. Give the child milk.
2. Give the child syrup of ipecac.
3. Call the poison control center.
4. Take the child to the emergency department. |
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Definition
| 3. Call the poison control center. |
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Term
A couple is with their adolescent daughter for a school physical. The parents tell you that they are worried about all the safety risks affecting this age. As you plan to teach the parents about these risks, you remember that adolescents are at a greater risk for injury from:
1. Home accidents
2. Physiological changes of aging
3. Poisoning and child abduction
4. Automobile accidents, suicide, and substance abuse |
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Definition
| 4. Automobile accidents, suicide, and substance abuse |
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Term
During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurse's initial intervention would be to:
1. Insert a urinary catheter
2. Ask the physician to order a restraint
3. Assign a staff member to stay with the client
4. Provide scheduled toileting during the night shift |
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Definition
| 4. Provide scheduled toileting during the night shift |
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Term
Lisa, a nurse assistant, is working with you during your shift. One of your clients has upper limb restraints. In delegating care of this client to the Lisa, you would tell her to:
1. Move the client to a room closer to the nurses' station
2. Check to see if the client can have a medication for sleep
3. Call the physician if the client becomes more agitated with the restraint
4. Report any signs of redness, excoriation, or constriction of circulation under the restraint |
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Definition
| 4. Report any signs of redness, excoriation, or constriction of circulation under the restraint |
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Term
The family of your confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to handle this situation would be to:
1. Ask them to stay with the client at all times
2. Inform them of the risks associated with side rail use
3. Thank them for being conscientious and put the four rails up
4. Provide the client a one-to-one sitter while the side rails are up |
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Definition
| 2. Inform them of the risks associated with side rail use |
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Term
During your assessment of a 56-year-old man, he reports increased alcohol consumption due to stress at work. One of your expected outcomes for this client will be to:
1. Decrease stress in his life
2. Teach him ways to promote sleep
3. Decrease his alcohol intake during stress
4. Provide the client with resources for stress management classes |
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Definition
| 4. Provide the client with resources for stress management classes |
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Term
Health care workers who have direct contact with individuals suspected of being contaminated with anthrax should (select all that apply):
1. Have the client remove clothing and place in a sealed biohazard bag
2. Instruct client to wash hands and exposed areas with soap and water
3. Wear an isolation gown, gloves, and high-efficiency particulate air (HEPA) mask
4. Prepare the client for transfer to the radiology department for a chest x-ray examination |
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Definition
| 1. Have the client remove clothing and place in a sealed biohazard bag |
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Term
A child you are caring for in the hospital starts to have a grand mal seizure while playing in the playroom. What is the most important intervention you can do during this situation?
1. Begin cardiopulmonary respiration.
2. Restrain the child to prevent injury.
3. Place a tongue blade over the tongue to prevent aspiration.
4. Clear the area around the child to protect the child from injury |
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Definition
| 4. Clear the area around the child to protect the child from injury |
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