Fundamentals Of Nursing NCLEX Quiz 12

1. At the end of the shift. the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take?

Complete an occurrence report before leaving.

Do nothing; the next nurse will document it was done.

Write the note of the dressing change into an earlier note.

Make a late entry as an addition to the narrative notes.

If the nurse fails to make an important entry while charting. she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted. there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore. the nurse on the incoming shift would not record the wound change as performed.

Explanation

If the nurse fails to make an important entry while charting. she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted. there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore. the nurse on the incoming shift would not record the wound change as performed.

2. When the nurse completes the patient's admission nursing database. the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding?

NA

NDA

NKA

NPO

The nurse can use the medical abbreviation NKA. which means no known allergies. to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth.

Explanation

The nurse can use the medical abbreviation NKA. which means no known allergies. to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth.

3. Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system?

It includes organizational reports of unusual occurrences that are not part of the client’s record.

This type of system consists of combined documentation and daily care plans.

It improves interdisciplinary collaboration that improves efficiency in procedures.

This type of system tracks medication administration and usage over 24 hours.

The EHR has several benefits for use. including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage.

Explanation

The EHR has several benefits for use. including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage.

4. The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets:

Are comprehensive charting forms that integrate assessments and nursing actions

Contain only graphic information. such as I&O. vital signs. and medication administration

Are used to record routine aspects of care; they do not contain assessment data

Contain vital data collected upon admission. which can be compared with newly collected data

Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions. such as wound care. treatments. or IV fluid administration. are also included. Graphic information. such as vital signs. I&O. and routine care. may be found on the graphic record. The admission form contains baseline information.

Explanation

Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions. such as wound care. treatments. or IV fluid administration. are also included. Graphic information. such as vital signs. I&O. and routine care. may be found on the graphic record. The admission form contains baseline information.

5. The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following?

Team nursing

Case method nursing

Functional nursing

Primary nursing

With team nursing. an RN or LVN is paired with a NAP. The pair is then assigned to render care for a group of patients. In case method nursing. one nurse cares for one patient during her entire shift. Private duty nursing is an example of this care model. This medical surgical floor is following the functional nursing model of care. in which care is partitioned and assigned to a staff member with the appropriate skills. For example. the NAP is assigned vital signs. and the LVN is assigned medication administration. When the primary nursing model is utilized. one nurse manages care for a group of patients 24 hours a day. even though others provide care during part of the day.

Explanation

With team nursing. an RN or LVN is paired with a NAP. The pair is then assigned to render care for a group of patients. In case method nursing. one nurse cares for one patient during her entire shift. Private duty nursing is an example of this care model. This medical surgical floor is following the functional nursing model of care. in which care is partitioned and assigned to a staff member with the appropriate skills. For example. the NAP is assigned vital signs. and the LVN is assigned medication administration. When the primary nursing model is utilized. one nurse manages care for a group of patients 24 hours a day. even though others provide care during part of the day.

6. Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration?

Respiratory therapist

Occupational therapist

Dentist

Speech therapist

Respiratory therapists provide care for patients with respiratory disorders. Occupational therapists help patients regain function and independence. Dentists diagnose and treat dental disorders. Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the risk.

Explanation

Respiratory therapists provide care for patients with respiratory disorders. Occupational therapists help patients regain function and independence. Dentists diagnose and treat dental disorders. Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the risk.

7. In the United States. the first programs for training nurses were affiliated with:

The military

General hospitals

Civil service

Religious orders

When the Civil War broke out. the Army used nurses who had already been trained in religious orders. Although the Army did provide some training. it occurred later than in the religious orders. Although nurses were trained in hospitals. the training and the hospitals were affiliated with religious orders. Civil service was not mentioned in Chapter 1 and was not a factor in the early 1800s. Nursing started with religious orders. The Hindu faith was the first to write about nursing. In the United States. all training for nurses was affiliated with religious orders until after the Civil War.

Explanation

When the Civil War broke out. the Army used nurses who had already been trained in religious orders. Although the Army did provide some training. it occurred later than in the religious orders. Although nurses were trained in hospitals. the training and the hospitals were affiliated with religious orders. Civil service was not mentioned in Chapter 1 and was not a factor in the early 1800s. Nursing started with religious orders. The Hindu faith was the first to write about nursing. In the United States. all training for nurses was affiliated with religious orders until after the Civil War.

8. Which of the following aspects of nursing is essential to defining it as both a profession and a discipline?

Established standards of care

Professional organizations

Practice supported by scientific research

Activities determined by a scope of practice

The American Nurses Association (ANA) has developed standards of care. but they are unrelated to defining nursing as a profession or discipline. Having professional organizations is not included in accepted characteristics of either a profession or a discipline. A profession must have knowledge that is based on technical and scientific knowledge. The theoretical knowledge of a discipline must be based on research. so both are scientifically based. Having a scope of practice is not included in accepted characteristics of either a profession or a discipline.

Explanation

The American Nurses Association (ANA) has developed standards of care. but they are unrelated to defining nursing as a profession or discipline. Having professional organizations is not included in accepted characteristics of either a profession or a discipline. A profession must have knowledge that is based on technical and scientific knowledge. The theoretical knowledge of a discipline must be based on research. so both are scientifically based. Having a scope of practice is not included in accepted characteristics of either a profession or a discipline.

9. Which of the following is/are an example(s) of a health restoration activity? Select all that apply.

Administering an antibiotic every day

Teaching the importance of handwashing

Assessing a client’s surgical incision

Advising a woman to get an annual mammogram after age 50 years

Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client’s surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness.

Explanation

Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client’s surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness.

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10. Which of the following is/are an example(s) of theoretical knowledge? Select all that apply.

Antibiotics are ineffective in treating viral infections.

When you take a patient’s blood pressure. the patient’s arm should be at heart level.

In Maslow’s framework. physical needs are most basic.

When drawing medication out of a vial. inject air into the vial first.

Theoretical knowledge consists of research findings. facts (e.g.. “Antibiotics are ineffective . . .” is a fact). principles. and theories (e.g.. “In Maslow’s framework . . .” is a statement from a theory). Instructions for taking a blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it.

Explanation

Theoretical knowledge consists of research findings. facts (e.g.. “Antibiotics are ineffective . . .” is a fact). principles. and theories (e.g.. “In Maslow’s framework . . .” is a statement from a theory). Instructions for taking a blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it.

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