Which nursing diagnosis is priority?

Impaired gas exchange r/t chronic bronchial inflammation

When teaching an elderly pt about changing his dressing, the nurse would most appropriately:

be certain the pt is wearing his glasses and/or hearing aid.

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

Patient refuses the 0900 dose of digoxin.

THE PURPOSE OF THE NURSING ASSESSMENT IS TO:

DEVELOP AN INDIVIDUALIZED CARE PLAN

How is inspection performed?

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

Give some examples of non-verbal communication

signs, symbols and pictures, proximity & appropriate use of touch, posture, body language and gesture

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

Nursing interventions should be charted chronologically

narrative charting is

free text description of the patient status

When should the nurse assess pain?

Whenever a full set of vital signs is taken

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

Providing feedback regarding the conveyed message

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

Completes a comprehensive database.

Charting by exception (CBE) means

abnormal patient responses are highlighted.

For communication to be effective:

use words that have same meaning for the sender & receiver

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

If the provider does not have ready access to internet.

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

lying supine with a pillow under the knees

Requirements for nursing documentation do not include

nursing opinions of the patient’s needs.

It is okay to make a correction on RN's charting if:

RN signs his/her name next to correction

When caring for a client who has a hearing loss, the nurse should

Face the client when speaking to the client

What is SOAPIER charting?

All of the above plus Intervention, Evaluation, Revision

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

What about late charting after someone has already charted?

Chart after circle the time write late entry and chart

Non-verbal communication includes;

body language, eye contact and gestures

The assessment step of the nursing process involves

Getting information about the resident and reviewing it

If you make an error in charting, what do you do?

Draw a line through, date, time and initial

An experienced nurse would not intervene if they heard a new nurse

Directing a conversation during the assessment process

The acronym IPA in nursing assessment stands for:

Inspection, Palpation, Auscultation

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

PNR 104: Week 4 Flashcards | StudBud