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6 Cards in this Set

  • Front
  • Back
Which action by a nurse ensures confidentiality of a client’s computer record?

A. The nurse logs on to the client’s file and leaves the computer to answer the client’s call light.
B. The nurse shares her computer password.
C. The nurse closes a client’s computer file and logs off.
D. The nurse leaves client computer printouts at the computer workstation.
A. Leaving the computer when it is on endangers the client’s confidentiality.
B. Sharing a password endangers the client’s confidentiality.
*C. Correct. Closing a file and logging off ensure client confidentiality.
D. Leaving client printouts by the computer station endangers the client’s confidentiality.
During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client’s blood pressure (B/P) seems high. What is the next step?

A. Ask the client about past blood pressure ranges.
B. Review the graphic record on the client’s record.
C. Examine the medication record for antihypertensive medications.
D. Review the progress notes included in the client’s record.
A. Verbal information is not appropriate for validating assessment that is measurable. This is more appropriate for pain or dizziness.
*B. Correct. The graphic record provides the trend of the vital signs.
C. The medication record would not include documentation of blood pressure ranges.
D. The progress notes provide information about how the client is progressing. It may have information about the client’s BP if it was a problem. However, the best answer is to review the graphic record.
A 74-year-old female is brought to the emergency department with right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appear to be cigarette burns on the client’s inner thighs. Which of the following is the most appropriate documentation about the skin lesions?

A. Six round skin lesions, partially healed, on the inner thighs bilaterally
B. Several burned areas on both of client’s inner thighs
C. Multiple lesions on inner thighs possibly related to elder abuse
D. Several lesions on inner thighs similar to cigarette burns
*A. Correct. This description is the most specific, nonassuming, and nonjudgmental charting.
B. Option B could be more specific by describing the lesions and not calling them “burns.”
C. Option C is making a judgment of elder abuse without investigation.
D. Option D is making an assumption that the lesions are from cigarette burns.
When writing descriptive nurses’ notes, a nurse does NOT chart normal assessment data.
He charts only unusual findings or those that deviate from established norms. What kind
of charting is this nurse using:

A. Traditional narrative
C. Focus®
D. Charting by exception
Answer: D – Charting by exception

Rationale: Traditional narrative charging includes all assessment findings (e.g., lungs clear to auscultation). SOAP charting also includes all assessment findings for each problem for which information is charted. Focus® charting includes all assessment findings for each topic for which
information is charted.
The nurse records, “NG tube irrigated with 35 cc normal saline.” In SOAP charting,
under which section is this to be written?

A. S
B. O
C. A
D. P
Answer: B – O. Objective Data in SOAP charting includes client data and nursing interventions.

Rationale: “S” includes subjective data: what the client says. “A” represents assessment, which is an interpretation of the S and O data. “P” represents the plan, or what the nurse plans to, but
has not yet, done.
What is the function of standardized care plans?

A. Provide individualized care for a particular patient
B. Guide the nurse in providing essential nursing care to specified types of patients
C. Ensure that the optimum standards of care are provided for each patient
D. Provide rationale for the nursing interventions
Answer: B – Guide the nurse in providing essential nursing care to specified types of patients

Rationale: When standardized care plans are used, the nurse must alter them to meet each individual patient’s needs. As printed, they identify problems and nursing interventions that are common to the identified situation, not to the person. Standards of care ensure minimum safe
care, not optimum care. Rationales are explanations of why the care is expected to be effective; standardized care plans are guides for care.