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19 Cards in this Set
- Front
- Back
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The nurse is receiving a phone order from a health care provider. How will the nurse make sure that the providers order is received without error? A. Advise the health care provider that the order must be written on the chart within the next 24 hours B. Ask the nurse in charge to come to the phone to take the order C. Write the order without using any unclear or unapproved abbreviations D. Repeat the order, write the order verbatium, and read it back to the provider |
D. Repeat the order, write the order verbatim, and read it back to the provider These are the steps recommended to confirm that the order was understood correctly, as well as communicationed correctly. |
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ISBARR tool |
Identification(pt name), Situation(current physical status), Background (activities that contributed to current status), Assessment (Problems that occurred during shift), Recommendations(nursing care to address problems , Response(readback information) |
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A nurse is working on a busy orthopedic floor and is on the phone with the floor manager when a physician comes up and gives a verbal order for pain meds on an assigned pt. The physician then leaves the unit. Which action by the nurse would be the most appropriate response? A. Write down the order and admin the med B. Put the nurse manager on hold and ask the physician to write the order C. Ignore the physician and cont the converstaion with the nurse manager D. Write down the order and document it as a telephone order |
B. Put the nurse manager on hold and ask the physician to write the order. Verbal orders should never be accepted unless there is an emergency or the physician is in a sterile environment because there is too much oppourtunity for a transcribing error. |
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The nurse is reviewing ISBARR with a coworker at the end of the shift. Which statement indicates that they are discussing the situation component? A. The nurse states the patients name using two identifiers B. The nurse states that the pt was hospitalized for a broken tibia and that surgery is scheduled for later today C. The oncoming nurse acknowledges that infor that has been received D. The nurse states an opinion on what is happening with the patient |
B. The nurse states that the pt was hospitalized for a broken tibia and that surgery is scheduled for later today |
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A nurse is working on a med surg unit and receives phones call from a physician who would like to give orders for a new pt. What should the nurse do to make the telephone order safer for the patient? (select all that apply) A. Refuse to accept the telephone order and request that the physician come write the order B. Accept the order and perform a read back C. Write down the telephone order as it is being given D. Accept the telephone order, but write down later E. Ask another nurse to accept the telephone order |
B,C |
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Which action can the nurse take during report to ensure pt safety? (select all that apply) A. give report at the bedside B. give report while the nurse is finishing up charting on another pt, so that the new nurse doesn't have to wait C. Use ISBARR during shift change report D. Focus on giving report, not on answering telephones E. Be prepared for report |
A,C,D,E |
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During clinical the student nurse is assigned a patient scheduled to undergo numerous treatments. The student decides it is not possible to complete all the needed treatments in the time scheduled for this clinical day. The student nurse consults with the clinical instructor to A. delegate B. Prioritize C. Procrastinate D. Do the easiest treatment first |
B. Prioritize |
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The instructor has suggested that the student nurse could improve organizational skills and manage time better by scheduling selected nursing activities in the daily assignment. Which activity should be scheduled? A. Suctioning the tracheostomy B. Administering medications C. Assessing patient knowledge of colostomy care D. Assisting a patient with person hygiene |
B. Administering medications Medications are the most time sensitive issue in nursing care delivery |
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A nurse is assigned to care for five patients. The nurse is concerned about the ability to care for this many patients The nurse needs to A. Delegate one of the patients to someone else B. Prioritize the needs of the patients and determine the sickest patient C. Procrastinate and hope that someone will offer assistance D. Do the easiest patient first to allow more time for sicker patients |
B. Prioritize the needs of the patients and determine the sickest patient Sickest patients always come first because of the multiple complex treatments they may need |
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Which statement by the nurse manager shows understanding of what initiated the development of the team strategies and tools to enhance performance and patient safety (STEPPS)? A. The increased need for health care coverage B. The need for more qualified nurses C. A need for a teamwork system focused on improving communication and teamwork D. The increased cost of health care |
C. A need for teamwork system focused on improving communication and teamwork Evidenced based teamwork system focused on improving communication and teamwork skills in the health care industry to improve patient outcomes. |
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The nurse manager is updating unit staff on findings by The Joint commission. Which of the following statements shows an understanding of untoward events in the hospital setting? The primary cause of untoward events is A. Unclear ineffective communication B. Unclear chain of communication for reporting C. ineffective reporting of untoward events D. Lack of consistent supervision of nursing staff |
A. Unclear ineffective communication nearly the root cause for 70% of all sentinel events reported. The majority of those untoward events involved communication failure. |
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The nurse receives report on an assigned group of patients. Which patient would the nurse assess first? A. A patient 2 days postopertaive who is complaining of pain B. An older adult patient reported to have increasing lethargy and confusion C. A newly admitted patient with a BUN of 32 mg/dL D. A hypertensive patient complaining of severe mid-sternum pain |
D. A hypertensive patient complaining of severe mid-sternum pain |
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The charge nurse is assigning patient care activities to the nursing care team. In supervising the team, what is the most effective activity to determine that the nursing care has been completed satisfactorly? A. Have hourly checks with personnel to determine how effectively nursing care is being compeleted B. Review with personnel at the end of the shift regarding the status of patients and how care was delivered. C. Discuss with each person the status of their assigned patients and what type of nursing care that has been completed D. Schedule rountine patient care rounds to evaluate the patients and the nursing care that has been completed. |
A Supervision entails providing direction, evaluation, and follow up by the nurse regarding the nursing care assigned. The only way the nurse can determine whether the care has been done satisfactorily is to monitor the task(hourly checks with personnel) and evaluate the patient. Waiting until the end of the shift could lead to problems not being assessed early to prevent complications. Scheduling rounds allows the nurse to evaluate the patient, however communication with the nursing team is important to determine if care is administered satisfactorly |
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A nurse has received report on assigned patients and is prioritizing their care. Which of the following patients should the nurse assess first? A. A female patient who is complaining of a headache B. A patient who has just returned from surgery and has saturated his dressing C. A patient with a femur fracture that is requesting pain medications D. A male patient who needs to use the bathroom |
B The nurse should assess patients using maslows hierarchy of needs or the ABC system. |
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A nurse has been assigned the following patients. Which patient is a priority to assess first? A. A patient with abdominal pain B. A patient who has been NPO all morning and wants to eat C. A patient with pneumonia and 02 saturation of 88% D. A patient complaining of ear pain |
C |
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The nurse wants to anticipate patient needs in order to increase patient satisfication and decrease the use of call bells in the assigned section. What actions can be taken to achieve this? A. Tell patients to turn on their call bells if they need something B. Perform hourly rounding on each patient C. Check on the patient every 2-3 hours D. Check on the patient only when medication needs to be administered |
B |
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The charge nurse is determining which activities to delegate to the nursing assistant. Which of the following would not be appropriate for the charge nurse to delegate to the nursing assistant? A. Changing solid linen B. Taking a blood pressure on someone receiving blood C. removing a urinary catheter D. Assessing a patients lung sounds |
D. Assessing a patients lung sounds when delegating care the charge nurse must remember that she cannot delegate nursing judgement. Therefore, the nurse cannot delegate the task of assessing lung sounds. This is a task that must be performed by the nurse. Taking blood pressures, removing urinary catheters, and changing bed linens are all activities that can be delegated. |
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A nurse is working with a nurse aide to care for a group of patients Which of the following activities would be inappropriate to delegate to the nurse aide? A. Providing discharge instructions to a patient B. refilling water containers C. Obtaining a lift to help a patient out of the chair D. Feeding a patient who is unable to feed himself |
A. Providing discharge instruction to a patient It is the nurses responsibility to provide discharge instructions to patients and to assess their understanding of them. All other answers can be delega |
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The nurse manager is in charge of a busy nursing unit. Today the nurse manager is planning to evaluate the work of nurses on the unit. Which of the following actions would help complete this task in an effective manner? (select all that apply) A. Provide feedback as necessary to staff B. Verify the tasks are being performed according to standards of practice C. Allow nurses to complete all tasks, even if performed incorrectly D. Provide directions with clear expectations of how the task is to be performed E. Evaluate the performance of the task by the staff |
A,B,D,E |
