Nursing 231 Final Exam Questions with 100% Correct Answers

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? a. Avoid rushing when charting an entry. b. Use correction fluid to remove the entry. c. Draw a single line through the statement and initial it. d. Enter only objective and factual information about the patient. Correct Answer d. Enter only objective and factual information about the patient. A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: a. Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. b. Gives a newly ordered medication before entering the order in the patient's medical record. c. Reads the orders back to the health care provider after receiving them and verifies their accuracy. d. Asks the preceptor to listen in on the phone conversation. Correct Answer b. Gives a newly ordered medication before entering the order in the patient's medical record. As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? a. The patient has a defiant attitude and is demanding his test results. b. The patient appears to be upset with his nurse because he wants his test results immediately. c. The patient is demanding and complains frequently about his doctor. d. The patient stated that he felt frustrated by the lack of information he received regarding his tests. Correct Answer d. The patient stated that he felt frustrated by the lack of information he received regarding his tests. You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? a. HIPAA allows all hospital staff access to your medical record. b. HIPAA limits the information that is documented in your medical record. c. HIPAA provides you with greater control over your personal health care information. d. HIPAA enables health care institutions to release all of your personal information to improve continuity of care. Correct Answer c. HIPAA provides you with greater control over your personal health care information. A patient asks for a copy of her medical record. The best response by the nurse is to: a. State that only her family may read the record. b. Indicate that she has the right to read her record. c. Tell her that she is not allowed to read her record. d. Explain that only health care workers have access to her record. Correct Answer b. Indicate that she has the right to read her record. Which of the following charting entries is most accurate? a. Patient walked up and down hallway with assistance, tolerated well. b. Patient up, out of bed, walked down hallway and back to room, tolerated well. c. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. d. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. Correct Answer d. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? a. Information technology. b. Electronic health record. c. Personal health information. d. Administrative information system. Correct Answer b. Electronic health record. You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) a. The patient's name, age, and admitting diagnosis b. Allergies to food and medications c. Your evaluation that the patient is "needy" d. How much the patient ate for breakfast e. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol Correct Answer a. The patient's name, age, and admitting diagnosis b. Allergies to food and medicationse. d. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: a. Documented medication given by another nursing student.