During the assessment phase of the nursing process, the nurse

gathers, organizes, & documents data in a logical database.

What is another purpose of charting?

Communication tool for the staff and physicians

The assessment step of the nursing process involves

Getting information about the resident and reviewing it

What is SOAPIER charting?

All of the above plus Intervention, Evaluation, Revision

Which of the following strategies might a nurse use to increase compliance with education?

Include the client and family as partners.

A patient refuses a dose of medication. How should the nurse document the event?

Patient refuses the 0900 dose of digoxin.

Which attributes are important in nursing documentation? (Select all that apply.)

Accuracy, Timeliness, Factual basis

What about late charting after someone has already charted?

Chart after circle the time write late entry and chart

While assessing the lymph nodes, the nurse should

Lightly palpate superficial lymph nodes with the pads of the fingers

Assessment in Nursing process includes:

Collecting data, Categorizing of data, recording of data, Utilization of systematic & ongoing process

Which of the following guidelines for charting patient information is accurate?

Nursing interventions should be charted chronologically

Under which circumstance would a nurse enter an order for a physician?

If the provider does not have ready access to internet.

Which of the following is an appropriate assessment during abdominal auscultation?

Listening for 5 minutes to determine absent bowel sounds

What is charting by exception?

Charting only the abnormal findings

The proper positioning of the patient for an abdominal examination is;

lying supine with a pillow under the knees

Why is communication important to the assessing step of the nursing process?

The major focus of assessing is to gather information.

Non-verbal communication includes;

body language, eye contact and gestures

Which nursing diagnosis is priority?

Impaired gas exchange r/t chronic bronchial inflammation

Critical thinking skills during the assessment phase of the nursing process ensures that the RN

Completes a comprehensive database.

For communication to be effective:

use words that have same meaning for the sender & receiver

What action by the nurse would most ensure accurate interpretation of patient communication?

Providing feedback regarding the conveyed message

Requirements for nursing documentation do not include

nursing opinions of the patient’s needs.

Which one of the following statements regarding nursing documentation is correct?

It must be patient centred and objective

How is inspection performed?

Use senses (vision, smell, hearing) to detect normal/abnorm

Professional misconduct around nursing documentation includes:

failing to keep records, falsifying a document

The acronym IPA in nursing assessment stands for:

Inspection, Palpation, Auscultation

Which are communication blocks?

Giving false reassurance, Agreeing/disagreeing, Asking “Why?”, Giving advice

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PNR 104: Week 4

76 termsStudBud Administration37 plays

physical assessment, nurse/patient communication and documentation

Flashcards76 cardsFPractice quizPHost liveL

Questions 76

Answers

1
Nursing notes and nursing documentation are NOT covered in the Health Information Privacy Code.
False
True
2
During the assessment phase of the nursing process, the nurse
establishes a nursing diagnosis for the nursing care plan.
gathers, organizes, & documents data in a logical database.
develops a care plan to meet the patient’s nursing needs.
begins to formulate plans for providing nursing intervention
3
Charting can also be used for Research and data collection
False
True
4
Charting in which the nurse writes a progress note that relates to one health problem is a:
SOAP note
Flow sheet
Narrative note
PIE note
5
What is another purpose of charting?
Busy work
Make the patient comfortable
Communication tool for the staff and physicians
Shows caring
6
In what sequence do you complete a physical assessment
Cardiovascular first
Toes to head
Head to toe
GI/ GU first
7
All of the following are places that the nurse will auscultate the heart except:
mitral
atrial
pulmonic
aortic
8
The assessment step of the nursing process involves
Identifying health problems and resident needs
Getting information about the resident and reviewing it
Setting goals and creating a care plan
Decide if goals were met
9
What is SOAPIER charting?
All of the above plus Intervention, Evaluation, Revision
More dove soap used
10
Which of the following strategies might a nurse use to increase compliance with education?
Use short, simple sentences for all ages.
Include the client and family as partners.
Maintain clear role as the authority.
Provide verbal instruction at all times.
11
A patient refuses a dose of medication. How should the nurse document the event?
0900 dose of digoxin not given.
Patient is uncooperative & refuses the dose of digoxin.
Patient is belligerent and refuses the 0900 dose of digoxin.
Patient refuses the 0900 dose of digoxin.
12
The basic guideline used for nursing documentation is:
HIPAA.
the patient’s diagnosis
the Nursing process (ADPIE)
the Code of Ethics.
13
what charting style highlights the pts concerns, problems and strengths?
problem-oriented system
source oriented charting
narrative charting
focus charting
14
Which is non-therapeutic communication?
What you need is a husband-ectomy.
Why did you take off your shoes?
All of these.
What did you say? Can you do it? What's your opinion?
15
Which attributes are important in nursing documentation? (Select all that apply.)
Inconsequentiality
Accuracy
Timeliness
Factual basis
16
Olfaction is:
The sense of vision
The sense of smell
The sense of hearing
The sense of touch
17
What about late charting after someone has already charted?
Chart after circle the time write late entry and chart
Throw away the entire page and start over
18
While assessing the lymph nodes, the nurse should
Palpate the deep cervical & supraclavicular nodes last
Use the tips of the 2nd, 3rd, & 4th fingers to apply deep palpation
Apply gentle, firm pressure to deep lymph nodes
Lightly palpate superficial lymph nodes with the pads of the fingers
19
Assessment in Nursing process includes:
Collecting data
Categorizing of data
recording of data
Utilization of systematic & ongoing process
20
Charting by exception implies that the patient meets all standards unless otherwise documented.
True
False
21
Which of the following guidelines for charting patient information is accurate?
Charting should be done in pencil to facilitate correction
Nursing interventions should be charted chronologically
Correction fluid should be used to correct charting mistakes
If a procedure is repeated often, using dittos is acceptable
22
Under which circumstance would a nurse enter an order for a physician?
If the nurse was instructed by the provider
The provider is on break
If the provider is at home
If the provider does not have ready access to internet.
23
In a patient unable to sit, how should the nurse position the pt for an assessment?
Lithotomy
Sims
Dorsal recumbent
Semi-fowlers
24
Which of the following is an appropriate assessment during abdominal auscultation?
Listening for 5 minutes to determine absent bowel sounds
Hearing 50 audible bowel sounds in one minute
Using the stethoscope diaphragm to listen for aorta buits
Listening left of the umbilicus above the ileocecal valve
25
What is charting by exception?
Charting only the abnormal findings
Charting everything in quotes
Charting the entire narrative
Charting everything the physician states
26
A correct physical assessment starts with:
Gastrointestinal assessment
Neurological assessment
Lung assessment
Cardiac assessment
27
The proper positioning of the patient for an abdominal examination is;
standing
side-lying
lying supine with a pillow under the knees
sitting upright
28
The best charting system to follow a patient through a timeline would be
Narrative
Problem, Intervention, Evaluation
Holistic Charting
Charting By Exception
29
What do you do for charting errors?
Scribble it out
Run away
White it out
Mark it out and initial it
30
Always start palpation at the site where the pain is located.
True
False
31
Why is communication important to the assessing step of the nursing process?
Assessing involves only nonverbal cues.
Assessing is primarily focused on physical findings.
The major focus of assessing is to gather information.
Written information is rarely used in assessment.
32
auscultation
listening with a stethoscope
counting your pulse
palpating the pulse with your fingers
a machine that produces a graph of heart activity
33
Non-verbal communication includes;
body language, eye contact and gestures
writing
spoken words, signs and symbols
yelling
34
Which of these can be a barrier to communication?
Active listening
Stereotyping
Rapport
35
Which nursing diagnosis is priority?
At risk bleeding r/t altered clotting
Activity intolerance r/t mismatch ventilation & perfusion
Acute pain related to surgical procedure
Impaired gas exchange r/t chronic bronchial inflammation
36
Critical thinking skills during the assessment phase of the nursing process ensures that the RN
Completes a comprehensive database.
Determines whether outcomes have been achieved.
Identifies pertinent nursing diagnoses.
Intervenes based on patient goals and priorities of care.
37
For communication to be effective:
add unrelated information
answers should not be specific
use terms that are unfamiliar to residents and families
use words that have same meaning for the sender & receiver
38
What action by the nurse would most ensure accurate interpretation of patient communication?
Verifying the patient’s emotional state
Writing down the patient’s conversational highlights
Assuming significant cultural differences exist
Providing feedback regarding the conveyed message
39
what is palpation?
examine by exercises
examine by xrays
examine by touch
40
T or F: Charting the abbreviation "WNL", means within normal limits
FALSE
True
41
Abnormal crackling sound heard during auscultation of the lungs while the patient is breathing in
Wheezing
Crackles
Rales
Stridor
42
Requirements for nursing documentation do not include
nursing diagnoses and interventions.
accurate, timely, and relevant information
all medications administered or withheld.
nursing opinions of the patient’s needs.
43
Which one of the following statements regarding nursing documentation is correct?
It must be patient centred and subjective
You may use any colour pen to document
It must be patient centred and objective
Incorrect entries should be erased with white out
44
How is inspection performed?
Use stethoscope to assess sounds
Use finger and tap on finger to detect sounds
Use fingers to feel normal/abnormal findings
Use senses (vision, smell, hearing) to detect normal/abnorm
45
The nurse is assessing a pt. Which finding might indicate that this pt is experiencing pain?
Heart rate 80 beats/min
Oxygen saturation 95%
Temperature 100.6°F
Blood pressure 160/82 mm Hg
46
Professional misconduct around nursing documentation includes:
failing to keep records
falsifying a document
keeping timely records
informing doctors of a patient's plan of care
47
The acronym IPA in nursing assessment stands for:
India Pale Ale
Intervention, Problem, Assessment
Inspection, Palpation, Auscultation
48
What are skills you might use to facilitate therapeutic communication with a patient?
Restating and reflecting
Ask family and friends to leave to ensure privacy
Discuss issues using the appropriate medical terminology
Asking specific questions requiring a yes or no answer
49
Crackles heard during auscultation can be a sign of what?
Lung cancer
Asthma
Pneumonia
Pneumothorax
50
The nurse will plan to offer the teaching session in a quiet area in order to:
make the environment more like a classroom.
ensure that the patient can hear what the nurse says.
reduce distractions.
provide absolute privacy.
51
Which are communication blocks?
Giving false reassurance
Agreeing/disagreeing
Asking “Why?”
Giving advice
52
Bowel assessment begins with
Auscultation
Palpation
Inspection
Percussion
53
Palpation is done by: ?
listening with stethescope
Observing the area
Feeling with the hand
Using a pressure hammer
54
Inspection, Palpation, and Auscultation would be ways to do a
Crepitus
Chest Assessment
Assessment of respiratory status
Pleural effusion
55
It is okay to make a correction on RN's charting if:
RN uses white out
RN signs his/her name next to correction
It is during the same shift
RN really didn't mean it
56
THE PURPOSE OF THE NURSING ASSESSMENT IS TO:
LOOK GOOD IN FRONT OF YOUR INSTRUCTOR
DEVELOP AN INDIVIDUALIZED CARE PLAN
BE NOSY
KILL SOME TIME
57
When Charting it is essential to record:
Comments of the family and guests
Safety Measures performed.
What co-workers observed
What co-workers did
58
What is a nurse required to do to adhere to the concept of confidentiality of a medical record?
Have a clinical reason for reading the record
Provide information only to an attorney
Provide information only to another nurse
Share information only with the family
59
An experienced nurse would not intervene if they heard a new nurse
Making stereotypical comments about a patient
Directing a conversation during the assessment process
Offering advice about which procedure to choose
Discussing rumors about hospital staff
60
When should the nurse assess pain?
During the admission interview
Every 4 hours for the first 2 days after surgery
Whenever a full set of vital signs is taken
Only when the patient complains of pain
61
When charting on a patient the first time, It is important to remember that:
Information can be erased if a mistake is made
Information in the chart can be shared with the family
the chart is a legal document
Test results are stored in a separate file
62
Steps of nursing process
AOPDA
ADDPE
ADPIE
POPPE
63
Give some examples of non-verbal communication
proximity & appropriate use of touch
signs, symbols and pictures
talking quietly and looking at the floor
posture, body language and gesture
64
Charting by exception (CBE) means
standardized terminologies are not used in documentation.
abnormal patient responses are highlighted.
all normal patient activities are documented.
all patient care is considered “normal.”
65
When performing a neurological exam the nurse includes assessment of which of the following?
Peripheral pulses
Capillary refill
Pupillary reaction
Bowel sounds
66
narrative charting is
a short reporting tool used for calling physicians
free text description of the patient status
focuses on patient problem
67
Light palpation is used to detect______; deep palpation used to assess______.
tenderness; temperature of skin
tympany; underlying organs
tenderness; underlying organs
underlying organs; tenderness
68
A nurse is caring for a client with a (DVT). What nursing assessment indicates a priority outcome has been met
Ambulates with assistance
Pain of 2/10 after medication
Oxygen saturation of 98%
Verbalizing risk factors
69
When teaching an elderly pt about changing his dressing, the nurse would most appropriately:
point out each mistake during the return demonstration.
talk rapidly to keep the patient from becoming tired.
wait for the pt to ask any questions about the procedure.
be certain the pt is wearing his glasses and/or hearing aid.
70
At what level does the nurse begin auscultation for the posterior lung?
Cervical 7
Thoracic 1
Cervical 5
Thoracic 10
71
Should the nurse give her approval or disapproval?
Yes
No
72
When caring for a client who has a hearing loss, the nurse should
Use only written communication with the client
Use hand gestures as much as possible
Face the client when speaking to the client
Yell at the client
73
communication is NOT important in nursing
False
True
74
If you make an error in charting, what do you do?
Throw away the entire days charting and start over
Scribble it out so no one can see it
Draw a line through, date, time and initial
Use white out
75
Which statement by the nurse best promotes reflection by a hospitalized patient?
“I don’t quite follow what you are asking.”
“You seem excited to be going home.”
“Your vital signs are excellent today.”
“Tell me when you started having pain.”
76
The nurse uses the flow sheet in patient care documentation primarily:
in computer charting to create visual graphs showing change.
to eliminate written narratives and to save time.
to track assessments, treatments, & frequently given care.
for continuity of care & exchange of info among disciplines.

PNR 104: Week 4 Flashcards | StudBud