NUR 211 Exam 2 Review Questions WITH CORRECT ANSWER 100%

NUR 211 Exam 2 Review Questions WITH CORRECT ANSWER 100% The hospital has just implemented the use of electronic health records (EHRs). While learning how to use this new system, the nurse realizes that EHRs may do which of the following? a. Limit access to the patient record to one person at a time b. Improve access to client information at the point of care c. Negate the use of nursing documentation d. increase the potential for medication errors - CORRECT ANSWER-b Use of EHRs can improve access to patients' information. An unlimited number of people at a time can access a patient's medical record. Nursing documentation is an essential part of nursing care, whether it is completed on paper or electronically. The potential for medication errors decreases when electronic medication administration records are used. Which statement best contributes to the nurse's documentation of assessment of patient status in the patient's medical chart? a. "patient had a good day with minimal complaints. Pt was pleasant and cooperative during morning care." b. "Pt complained that the nurse didn't come quickly enough when she pressed the call button." c. "Pt complained of pain 7 of 10 at 7:45 am. Received pain med at 8am, reporting pain 3 of 10 at 8:30am" d. "Pt was grumpy today, even after administration of pain medication, a back massage, and a nap" - CORRECT ANSWER-c This entry is concise, complete, and objective. It gives exact times, pain levels, and nursing interventions performed. Using terms like good or grumpy are subjective judgments or opinions and should be avoided. Stating a patient complaint would be okay if it listed specific times of occurrence, nursing assessment performed, and the nursing interventions performed to correct the issue. A patient requests a copy of his medical record. What is the correct response by the nurse? a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff. b. Tell him that the Code for Nurses does not allow you to give him access to his records. c. Acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy. d. Refer his request to the hospital administrator since all such requests need to go through proper channels - CORRECT ANSWER-c As part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and updated in 2009 in The American Recovery and Reinvestment Act (ARRA), patients' rights include obtaining, viewing, or updating a copy of their own medical records. Usually an EHR copy is sent to the patient within 30 days. Facilities can charge the patient for the cost incurred in copying and sending medical records. Methods for implementation vary by facility and type of medical record. The Code for Nurses does not control who has access to medical records. Requests would go through the medical records department, or whoever is responsible for obtaining and copying patient records. A patient's sister comes to visit and asks to read the patient's chart. What is the best response by the nurse? a. Settle her in a chair at the nurses' station and give her the chart. b. Respond that the contents of a patient's chart are private and confidential. c. Tell her she can read the chart only if the patient sits with her. d. Distract the sister by changing the subject and then walking away. - CORRECT ANSWER-b Without special permission from the patient, only those with a need-to-know-theinformation-for-care reasons have access to the medical record. The patient has a legal right to control access to personal information, and the nurse should not give the sister the chart for review, even with the patient present. It is best to be honest and explain the patient's legal rights rather than avoiding the subject. Which are reasons that accurate documentation in the medical record is important? (select all that apply) a. remimbursement for care b. evidence of care provided c. communication between health care providers d. nonlegal documentation of a nurse's actions e. promotion of continuity of care - CORRECT ANSWER-a, b, c, e Documentation in the medical record is important for reimbursement for care, for providing a record of services, for communication between providers, and for promoting continuity of care. The record is a legal document, not a non-legal document. Which note is an example of the S in SBAR? a. Patient resting; pain was rated 3 of 10 1 hour after receiving narcotic analgesic. b. Patient was admitted on evening shift with a fractured right femur after a fall at home. c. Patient's pain was rated 8 of 10 before administration of narcotic pain medication. d. Assess pain ever 2 hours, continue pain medication as prescribed, and provide backrub. - CORRECT ANSWER-a The S in SBAR stands for situation. In this case, the patient is resting, and the pain is rated 3 of 10 one hour after receiving a narcotic analgesic. Describing the admission reason and time provides the background (B). Assessment (A) of this patient revealed pain rated 8 of 10 before giving pain medication. The nurse's recommendation (R) is that pain should be assessed every 2 hours and that pain medications should be given as prescribed. Which attributes are important in nursing documentation? (select all that apply) a. Inconsequentiality b. Timeliness c. Relevancy d. Accuracy e. Factual basis - CORRECT ANSWER-b, c, d, e. Documentation should be completed in a timely manner, be relevant and concise, and be accurate and factual. Inconsequentiality suggests a lack of importance, and documentation is an important part of patient care and nursing responsibility When should administered medications be documented? a. At the end of a shift when all meds have been given b. As given to avoid the possibility of double dosing c. After every meal to document at least three times daily d. In pencil to allow for changes to be made - CORRECT ANSWER-b All medications and nursing care should be documented as it is completed to ensure that documentation occurs in a timely manner. Documentation should occur as soon as possible after assessment, interventions (including medication administration), condition changes, or evaluation. Documentation only at the end of a shift or after meals would not be timely and could lead to medication errors and fragmented care. Nursing documentation is a legal record and is done electronically or in ink so that it cannot be changed. Errors are corrected in a specific way depending on the type of charting, but the original documentation would still be accessible. What is an advantage of the use of paper medical records? a. charts with paper records are always available to all health care teams b. paper records do not need much storage space in the health care facility c. recording on paper does not require any special computer knowledge d. writing implements are always available on nursing units and patient rooms - CORRECT ANSWER-c No special computer or information technology knowledge is needed to record on a paper medical record. Paper charts are available to only one health care team member at a time. Paper records require a lot of storage space, or have to be scanned into an electronic record to reduce storage space. There is no guarantee that a pen will be available on a nursing unit or in a patient room. What is a purpose of a hand-off report? a. ensures continuity of care and patient safety b. keeps the doctor informed c. completed when a patient is discharged to his home d. determines patient assignments - CORRECT ANSWER-a A handoff report shares patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety. The handoff report is usually shared among direct caregivers. Doctors are kept informed verbally by the nurse, through SBAR reporting, and by accessing the EHR. A patient being discharged to home is given discharge instructions but is not being "handed off" to another caregiver, so a handoff report is not appropriate. Patient assignments are determined before a handoff report is needed and are based on patient acuity, staffing, and a number of other factors. The nurse is caring for a group of older adults. Which patients in this group are exhibiting normal signs of aging? (select all that apply) a. the patient with knee pain and wrinkles around the eyes b. the pt who needs reading glasses and states that food tastes bland c. the pt who is confused and does not know the current year d. the pt who states that constipation is an increasing problem e. the pt who is showing signs of depression and hopelessness - CORRECT ANSWERa,b,d Normal aging includes signs of decline in many organ systems. Knee pain, skin wrinkles, need for reading glasses, decline in taste buds, and constipation all can occur with aging. Normal aging does not include dementia or depression, even though these can both be diagnosed in the older adult population. Which term indicates a mental health disorder that is frequently seen in older adults? a. schizophrenia b. bipolar disorder c. depression d. posttraumatic stress disorder - CORRECT ANSWER-c Depression is one of the psychiatric illnesses appearing most frequently in the older adult population. Schizophrenia typically is seen in younger adult populations. Bipolar disorder is usually identified before age 65 years. PTSD can be seen in any age group and usually is related to previous experience of a traumatic event. Objective data can be gathered from the patient during which aspects of the physical assessment process? (select all that apply) a. patient interview b. health history c. general survey d. physical examination e. laboratory testing - CORRECT ANSWER-all of the above Which sequence best identifies the order in which the nurse should complete an abdominal assessment? a. Inspection, palpation, percussion, auscultation b. Auscultation, inspection, palpation, percussion c. Auscultation, palpation, percussion, inspection d. Inspection, auscultation, palpation, percussion - CORRECT ANSWER-B Which action by a patient with a family history of macular degeneration would demonstrate use of a prevention strategy that has been found to help prevent deterioration of the macula? a. using medicated eye drops b. avoiding the use of sunglasses c. taking vitamins B6 and B12 supplements d. minimizing intake of dietary antioxidants - CORRECT ANSWER-c Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip replacement who has acute confusion and incontinence? a. A room near the nurses' station and decreased sensory stimuli b. A pressure sensor alarm and a room near the nurses' station c. Side rails up and decreased sensory stimuli d. A 24-hour sitter and the patient's favorite TV program - CORRECT ANSWER-b The nurse is performing a fall risk assessment on a newly admitted patient. Which finding is a known risk factor for falls? a. medications b. urinary incontinence c. multiple comorbidities d. malnutrition - CORRECT ANSWER-b A patient is ordered to have a urine culture to rule out methicillin-resistant Staphylococcus aureus (MRSA). When obtaining this specimen, which personal protective equipment (PPE) should the nurse don? a gloves, mask, eye shield b. gloves, gown, shoe covers c. gloves, mask, hat d. gloves, gown, eye shield - CORRECT ANSWER-d An elderly client residing in the community with cardiopulmonary compromise and impaired ability to perform activities of daily living (ADLs) presents safety concerns to the nurse. Which is the greatest concern? a. ability to obtain and take medications correctly b. ability to safely get on and off a toilet c. ability to safely procure food and prepare meals d. ability to safely eat without choking - CORRECT ANSWER-b What other health care professional should the nurse consult when a patient has difficulty with ADLs and why? a. occupational therapist to evaluate the ability to perform ADLs b. physical therapist to evaluate the patient's need for assistive devices c. social worker to arrange for needed assistive devices d. area agency on aging to arrange for Meals on Wheels - CORRECT ANSWER-a A 56 YO man who has been staying at a cabin while hunting arrives at the emergency department with complaints of dizziness, light-headedness, and nausea. What does the nurse initially suspect? a. carbon monoxide poisoning b. lead poisoning c. radon exposure d. food poisoning - CORRECT ANSWER-a