NURSING FUNDAMENTAL
WEEK 6
Exam 5
Submissions
Here are your latest answers:
Question 1
Which statement is a recommended guideline for charting?
Response: Have the patient’s name and identification number on every sheet.
Correct answer: Have the patient’s name and identification number on every sheet.
Score: 2 out of 2 Yes
Question 2
An elderly patient’s respiratory rate (RR) is 24 breaths/min, and the patient’s breathing appears to be shallow. Which additional information could alert the nurse that the
patient is experiencing respiratory distress?
Response: The chest rises during inhalation
Correct answer: The nostrils are flaring
Score: 0 out of 2 No
Question 3
The primary health care provider instructs the licensed practical nurse/licensed vocational nurse (LPN/LVN) to medicate a patient if the patient’s body temperature rises
above 102F. In which section would the LPN/LVN record the information, using the SOAPIER documentation format?
Response: Intervention
Feedback: SOAPIER documentation consists of seven different charting sections, including Subjective, Objective, Assessment, Plan, Intervention, Evaluation, and
Revision. Intervention or implementation includes the specific care to be given or measures taken while providing care to the patient.
Correct answer: Intervention
Score: 2 out of 2 Yes
Question 4
A patient with an inflamed prostate has a prescription for the temperature to be taken every 4 hours. Which action would warrant correction if taken by the unlicensed
assistive personnel (UAP)?
Response: Attempting to take a rectal temperature
Correct answer: Attempting to take a rectal temperature
Score: 2 out of 2 Yes
Question 5
A nurse has delegated to an unlicensed assistive personnel (UAP) the task of obtaining vital signs from four different patients receiving antihypertensive medications.
Which blood pressure reading, when reported by the UAP, would the nurse need to act on immediately?
Response: 100/66
Correct answer: 198/110
Score: 0 out of 2 No
Question 6
A health care worker accidently faxes a copy of laboratory test results to an incorrect fax number. Which violation has occurred if the health care worker fails to get the
fax returned?
Response: Health Insurance Portability and Accountability Act (HIPAA)
Correct answer: Health Insurance Portability and Accountability Act (HIPAA)
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Score: 2 out of 2 Yes
Question 7
A nurse is caring for a gunshot victim with significant blood loss. When assessing the blood pressure in all extremities, the nurse is unable to auscultate any sounds.
Which assessment would provide the most appropriate information for the nurse at this time?
Response: Fluid and electrolyte assessment
Correct answer: Use of a doppler ultrasonic stethoscope
Score: 0 out of 2 No
Question 8
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
Response: Compare the current reading with the client's previously documented blood pressure readings.
Feedback: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first.
Correct answer: Compare the current reading with the client's previously documented blood pressure readings.
Score: 2 out of 2 Yes
Question 9
The nurse omits a dose based on personal judgment. Which note does the nurse document in the medication administration record (MAR)?
Response: The exact reason for the omission.
Correct answer: The exact reason for the omission.
Score: 2 out of 2 Yes
Question 10
Which statement demonstrates assessment according to SBAR documentation?
Response: "Mr. Jones presents with epistaxis (nosebleed) and significant bruising to the arms."
Correct answer: "Mr. Jones presents with epistaxis (nosebleed) and significant bruising to the arms."
Score: 2 out of 2 Yes
Question 11
The nurse is recording the vitals of a patient and finds the temperature to be 104.5 oF, pulse rate to be 95 beats/min, and respiratory rate to be 22 breaths/min. Which
activity by the patient is the likely cause for these alterations in the vital signs?
Response: Exposure to humid weather
Correct answer: Strenuous exercise
Score: 0 out of 2 No
Question 12
A patient with an abnormal laboratory value had discharge orders. The nurse assessed a patient and called the primary health care provider for a prescription. The nurse
read the phone prescription back to the primary health care provider and verified the dosage. Which tool did the nurse use to prevent a medication error caused by
communication?
Response: Situation, Background, Assessment, Recommendation, Read Back (SBARR)
Correct answer: Situation, Background, Assessment, Recommendation, Read Back (SBARR)
Score: 2 out of 2 Yes
Question 13
A nurse is working on the cardiac unit caring for a patient on a heart monitor. The nurse determines the patient’s heart rate to be 130 beats/min. Which term does the nurse
use to describe this heart rate?
Response: Tachycardia
Correct answer: Tachycardia
This study
Score: 2 outsource was downloaded by 100000820020768 from CourseHero.com on 04-04-2023 12:01:02 GMT -05:00
of 2 Yes
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