NUR 155 Exam 1 (Units 1 & 2)
Which action by a nurse ensures confidentiality of a client's computer
record?
1. The nurse logs on to the client's file and leaves the computer to answer the client's call light.
2. The nurse shares her computer password.
3. The nurse closes a client's computer file and logs off.
4. The nurse leaves client computer worksheets at the computer workstation. - ✔✔✔Answer: 3
Rationale: All of the other answers endanger the client's
confidentiality.
The case management model using critical pathways would be
appropriate for a client with which diagnosis?
1. Myocardial infarction (heart attack)
2. Diabetes, hypertension
3. Myocardial infarction, diabetes, hypertension
4. Diabetes, hypertension, an infected foot ulcer, senile dementia - ✔✔✔Answer: 1
Rationale: Critical pathways work best for clients with one diagnosis.
After making a documentation error, which action should the nurse take?
1. Use correcting liquid to cover the mistake and make a new entry.
2. Draw a line through it and write error above the entry.
3. Draw a line through it and write mistaken entry above it.
4. Draw a line through the mistake and write mistaken entry with initials above it - ✔✔✔Answer: 4
Rationale: It is the most complete answer. The client's record is a legal record and should not be altered
with correcting liquid. You may see "error" written above a mistake even though many authors suggest
not writing it. It is important to also put your name or initials next to the words of the mistaken entry.
, During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks
that the client's blood pressure (BP) seems high. What is the next step?
1. Ask the client about past blood pressure ranges.
2. Review the graphic record on the client's record.
3. Examine the medication record for antihypertensive
medications.
4. Review the progress notes included in the client's record. - ✔✔✔Answer: 2
Rationale: The graphic record provides the trend of the vital signs. Option 1, verbal information, is not
appropriate for validation assessment that is measurable. This is more appropriate for pain
or dizziness. The medication record would not include documentation of blood pressure ranges (option
3). The progress notes (option 4) provide information about how the client is progressing. It may have
information about the client's BP if it was a problem. The best answer is option 2.
A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse
represents effective nursing practice? Select all that apply.
1. Provides the medical diagnosis or reason for admission.
2. States the time the client last received pain medication.
3. Speaks loudly when giving report.
4. States priorities of care that are due shortly after the report.
5. Reports on number of visitors for each client. - ✔✔✔Answer: 1, 2, and 4
Rationale: Option 3 is incorrect because it could
be a HIPAA violation if others hear protected health information. Option 5 is not needed unless it is a
concern and it would not be done for every client.
Which charting entries are written correctly? Select all that apply.
1. MS 5 gr given IV for c/o abdominal pain
2. Lanoxin 0.25 mg given orally per Dr. Smith's stat order
Which action by a nurse ensures confidentiality of a client's computer
record?
1. The nurse logs on to the client's file and leaves the computer to answer the client's call light.
2. The nurse shares her computer password.
3. The nurse closes a client's computer file and logs off.
4. The nurse leaves client computer worksheets at the computer workstation. - ✔✔✔Answer: 3
Rationale: All of the other answers endanger the client's
confidentiality.
The case management model using critical pathways would be
appropriate for a client with which diagnosis?
1. Myocardial infarction (heart attack)
2. Diabetes, hypertension
3. Myocardial infarction, diabetes, hypertension
4. Diabetes, hypertension, an infected foot ulcer, senile dementia - ✔✔✔Answer: 1
Rationale: Critical pathways work best for clients with one diagnosis.
After making a documentation error, which action should the nurse take?
1. Use correcting liquid to cover the mistake and make a new entry.
2. Draw a line through it and write error above the entry.
3. Draw a line through it and write mistaken entry above it.
4. Draw a line through the mistake and write mistaken entry with initials above it - ✔✔✔Answer: 4
Rationale: It is the most complete answer. The client's record is a legal record and should not be altered
with correcting liquid. You may see "error" written above a mistake even though many authors suggest
not writing it. It is important to also put your name or initials next to the words of the mistaken entry.
, During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks
that the client's blood pressure (BP) seems high. What is the next step?
1. Ask the client about past blood pressure ranges.
2. Review the graphic record on the client's record.
3. Examine the medication record for antihypertensive
medications.
4. Review the progress notes included in the client's record. - ✔✔✔Answer: 2
Rationale: The graphic record provides the trend of the vital signs. Option 1, verbal information, is not
appropriate for validation assessment that is measurable. This is more appropriate for pain
or dizziness. The medication record would not include documentation of blood pressure ranges (option
3). The progress notes (option 4) provide information about how the client is progressing. It may have
information about the client's BP if it was a problem. The best answer is option 2.
A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse
represents effective nursing practice? Select all that apply.
1. Provides the medical diagnosis or reason for admission.
2. States the time the client last received pain medication.
3. Speaks loudly when giving report.
4. States priorities of care that are due shortly after the report.
5. Reports on number of visitors for each client. - ✔✔✔Answer: 1, 2, and 4
Rationale: Option 3 is incorrect because it could
be a HIPAA violation if others hear protected health information. Option 5 is not needed unless it is a
concern and it would not be done for every client.
Which charting entries are written correctly? Select all that apply.
1. MS 5 gr given IV for c/o abdominal pain
2. Lanoxin 0.25 mg given orally per Dr. Smith's stat order
