Nursing_Interventions_and_Clinical_Skills

The nurse admits a patient who is nonverbal and agitated. What can the nurse do to communicate effectively with the patient? a. Use a communication aid. b. Wait for family to arrive. c. Call interpreter services. d. Treat the patient for pain. ANS: A TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N Patients with sensory losses require communication techniques that maximize existing sensory and motor functions. Some patients are unable to speak because of physical or neurological alterations such as paralysis; a tube in the trachea to facilitate breathing; or a stroke resulting in aphasia, difficulty understanding, or verbalizing. Many types of communication aids are available for use, including writing boards, flash cards, and picture boards. The nurse needs to determine what will work for the patient. Waiting for family is unacceptable because the patient needs care and the family may be delayed or not come at all. Interpreter services are for patients who do not speak the language. The nurse should not assume the patient has pain before completing an assessment. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Assessment 9. A patient’s mother died several days ago. The patient begins to cry and states, “The pain of her death is impossible to bear.” Which statement by the nurse is the most effective response? a. “I was depressed last year when my mother died, too.” b. “I know things seem bleak, but you are doing so well.” c. “I can see this is a very difficult time for you right now.” d. “Should I cancel your appointment with the cardiologist?” ANS: C The nurse conveys empathy and respect by acknowledging the patient’s grief. This is an effective response and is likely to enhance the nurse–patient relationship because it is patient centered, displays caring and respect, and helps to make the patient feel accepted. Relating personal details about the nurse’s life redirects the focus of the communication to the nurse and fails to support the objectives of the nurse–patient relationship. Responding with a comment about the patient’s progress and asking about the cardiologist’s appointment ignores the patient’s grief and conveys a lack of respect and consideration. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 10. A patient who says that both parents died of heart disease early in life is waiting for diagnostic testing results. The patient is biting fingernails and pacing around the room. Which statement should the nurse use to clarify patient information? a. “I can see that you are anxious about dying.” b. “Tell me more about your family’s history.” c. “Do you have your parents’ medical records?” d. “I’m not sure that I understand what you mean.” ANS: B Asking for more information about the family’s history directs the patient to expand on a specific, pertinent topic and relate key details before moving to another topic. “Early in life” and “heart disease” need to be defined by the patient; “early in life” can indicate a wide range of ages, depending on the definition of “early,” and “heart disease” can mean conditions such as heart failure, coronary artery disease, valve disease, and arrhythmias. Until the patient discusses his particular concerns, the nurse cannot be sure about the source of his anxiety. Asking for the records can display a lack of respect by implying that the patient is an unreliable source for information. Stating that the nurse is not sure what the patient means is vague, leaving the patient to guess what the nurse wants to know. TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 11. The patient tells the nurse, “I must be very sick because so many tests are being performed.” Which statement does the nurse use to clarify the patient’s message? a. “I sense that you are very worried.” b. “Why do you mention this so frequently?” c. “We should talk about this more.” d. “Are you saying you think you are seriously ill?” ANS: D The nurse clarifies the patient’s message. This encourages the patient to expand on a thought or feeling that seems vague to the nurse. Pointing out that the patient has stated this before can be misinterpreted to mean that the patient is forgetful or annoying, and “why” questions tend to put people on the defensive. Stating that the nurse feels that the patient is worried is a suitable response but does not clarify what the patient actually said. Telling the patient he or she “should” talk about this topic is confrontational. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 12. The patient tells the nurse, “I want to die.” Which is the best response by the nurse to facilitate therapeutic communication? a. “Now why would you say a thing like that?” b. “Tell me more about how you’re feeling.” c. “We need to tell the provider how you feel.” d. “You have too much to live for to say that.” ANS: B The patient’s statement warrants further investigation to determine how serious the patient is about dying and whether he or she has a plan. To elicit more information from the patient in a respectful and caring manner, the nurse allows the patient to expand on the statement, “I want to die” by stating, “Tell me more.” The statement displays concern for and value of the patient by acknowledging the patient’s message and encouraging him or her to continue. Safety is a major concern when a patient wants to die, and the remaining options are likely to be perceived as patronizing and/or dismissive. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 13. The nurse is explaining a procedure to a 3-year-old patient. Which strategy would the nurse use for patient teaching? a. Ask the patient to draw her feelings. b. Show needles, syringes, and bandages. c. Tell the patient about postoperative pain. d. Use dolls and stories to explain surgery. ANS: D TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N Using dolls, stuffed animals, or puppets with stories is a suitable way to explain surgery to the 3-year-old patient because storytelling is a familiar communication method for the toddler’s developmental stage. A 3-year-old child is unlikely to understand an explanation about the surgery suited for an adult, and the discussion can frighten the child and upset the family or guardian. A 3-year-old child lacks the fine motor and cognitive skills to draw an abstract concept. A toddler is unlikely to understand and probably would be frightened by a discussion about postoperative pain. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 14. The nurse is caring for a patient who states, “I don’t feel well today.” Which is the best response by the nurse? a. Ask the patient to continue to describe the feeling. b. Measure the blood pressure and temperature. c. State that the patient’s diagnostic testing had normal results. d. Compare recent laboratory results with the prior results. ANS: A Because the patient’s statement is too vague, the nurse asks him or her to continue describing, “I don’t feel well today,” because many disorders begin with nonspecific complaints. Depending on the details the patient shares, the nurse plans and implements nursing care individualized to his or her description. This may include taking vital signs, and reviewing lab data, but before taking action the nurse needs more information. Telling the patient that test results are normal is dismissive of the concern. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 15. The nurse is caring for a patient who refuses to participate in physical therapy (PT) and states, “I really don’t like to exercise.” Which response by the nurse is most likely to help engage the patient in PT? a. “It makes the pain worse, doesn’t it?” b. “What don’t you like about exercise?” c. “You really should do these exercises.” d. “Do you like to do any other activities?” ANS: B The nurse asks an open-ended question using the patient’s words to uncover information about the patient’s refusal to participate in PT by asking what the patient dislikes about exercise. Using the patient’s words conveys acceptance and value because the nurse listened closely enough to repeat what the patient said. Asking the patient a yes-or-no question such as, “It makes the pain worse, doesn’t it?” is unlikely to promote further discussion because it is a closed, yes/no question. Telling the patient to do the exercises is giving advice; rather the nurse can tell the patient the reason for the therapy and the benefits of doing it or the risks of not doing it. Asking about other activities moves the focus away from the patient’s need for physical therapy. This is also a yes/no question. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N 16. The nursing staff are using the SBAR communication technique during patient hand-off communication. The circumstances leading up to the current status would be explained by the nurses during which step of the technique? a. Situation b. Background c. Assessment d. Recommendations ANS: B The background explains circumstances leading up to the situation. The situation explains what is happening at the present time. The assessment phase identifies what the problem is thought to be. The recommendations explain how to correct the problem. DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 17. The nursing staff are working with a postoperative patient from another culture who does not understand or speak the English language well. Which approach by the nurse would be best? a. Act out what the patient needs to do. b. Obtain a medical interpreter. c. Assess if the patient can read or write. d. Talk slowly when instructions are given. ANS: B A medical interpreter would be most helpful for effective communication. Acting out what the patient needs to do is ineffective and may be embarrassing to both the patient and the nurse. Since the patient and nurse do not speak a common language, defining the patient’s ability to read or write in his native language does not solve the communication problem. Talking slowly will not improve the patient’s ability to understand an unfamiliar language. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 18. The nurse is working toward discharging a patient. Which of following demonstrates patient engagement during the discharge process? a. Teaching the patient how to use his equipment b. Having the patient establish daily goals c. Reviewing the discharge instructions with the patient d. Including the family in the discharge planning ANS: B All of the answers are important to the discharge process but having the patient set his or her own daily goals establishes true patient engagement. The other interventions are performed by the nurse and do not really engage the patient. Patient engagement requires that the patient’s preferences be incorporated. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N 19. The registered nurse is orienting a new nurse to the unit. They are completing paperwork on a newly admitted patient. When the experienced nurse asks what the new nurse thinks the patient will need to learn for self-care at home, the new nurse expresses surprise. What statement by the registered nurse is most appropriate? a. “You should always at least start thinking about discharge planning.” b. “We don’t want to wait too long because unexpected things happen.” c. “The admitting nurse has to fill in all sections of this document.” d. “Best practice is to begin discharge planning on admission.” ANS: D Discharge planning should begin on admission to be accurate, thorough, and to allow the patient and/or family enough time to learn information or to master skills they will need at home. The other options may be at least partially true, but the only comprehensive answer is that it is best practice. DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 20. A student is watching a nurse perform a medication reconciliation prior to transferring the patient to a skilled nursing facility. What explanation of this process to the student is best? a. “It is required by the Joint Commission before discharge or transfer.” b. “It creates an accurate list of medications so errors do not occur later.” c. “It helps us recognize lapses in patients’ ability to remember their medications.” d. “Receiving facilities won’t accept patients without a reconciliation.” ANS: B Medication reconciliation is the process of creating the most accurate list of medications a patient is taking and comparing it to provider admission, transfer, and discharge orders. This is done in order to prevent medication errors at each transition. DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 21. A nurse is reviewing medications and treatments one final time before the patient goes home. The patient becomes agitated and says “I just can’t do this! I’m too upset to ever be able to learn this!” What action by the nurse is best? a. Provide immediate remediation on the knowledge and skills. b. Ask the patient if home health care might be acceptable. c. Request the provider re-examine all the discharge orders. d. Tell the patient you would like to understand what is most difficult. ANS: D Just prior to discharge, the nurse reviews the discharge orders and plans with the patient. When the patient cannot recall information or perform needed skills, the nurse can provide immediate re-teaching and skills practice. However, this patient is upset, so the nurse must first determine the most bothersome aspect of the situation, which may or may not include the instructions. The nurse must first assess this before deciding if home health care is acceptable or before asking the provider to review the orders to see if they are all necessary. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N MULTIPLE RESPONSE 1. During a home care visit, the patient experiences an angry outburst and hits the nurse on the thigh and yells at her. The patient continues to be threatening. What are the most appropriate initial actions by the nurse? (Select all that apply.) a. Increase the personal space between the nurse and patient. b. Call law enforcement to take the patient to the hospital. c. Restrain the patient’s hands to the chair. d. Be empathetic to the patient’s feelings and concerns. e. Call the nursing agency to ask for advice in working with this patient. f. Use a calm, quiet voice when talking with the patient. ANS: A, D, F The priority in this situation is the safety of both nurse and patient. The nurse should ensure there is adequate personal space between the two of them so the patient cannot strike the nurse. Being empathetic displays respect; even if the nurse disagrees with the patient’s perception, it is real to that person. Using a calm, quiet voice is a de-escalation technique. The patient may or may not need hospitalization, but calling the police would not be the first action. The patient’s hands should not be restrained as this could cause the patient to escalate and perhaps feel assaulted. The nursing agency should be consulted, but not as an initial action. The nurse needs to create an environment that is safe for both parties. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 2. Which of the following pieces of information should be included in a hand-off to ensure patient safety? (Select all that apply.) a. Code status b. Recent changes in condition c. Age d. Family visitation e. Use of oxygen ANS: A, B, E It is important to include information on a patient’s background, assessment, nursing diagnosis, interventions (including the patient’s response), family information, discharge plans, and current priorities when handing off your patient to another unit or area. However, only code status, recent changes in patient’s condition, and use of oxygen directly impact patient safety. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 3. A faculty member is explaining personal factors that influence communication. What factors does the faculty member include? (Select all that apply.) a. Perceptions b. Values c. Emotions d. Relationships TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N e. Pain ANS: A, B, C, D Although a patient’s pain may affect communication, it is not a personal factor as are perceptions, values, emotions, and relationships. DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N Chapter 03: Documentation and Informatics Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse discovers a medication error on another nurse’s documentation, so the nurse completes an incident report. Which statement should the nurse include in the report? a. “Nurse mistakenly gave the wrong dose of medication for pain.” b. “Nurse gave incorrect dose of pain medication, but patient is all right.” c. “Morphine 10 mg IM given rather than morphine 5 mg IM as ordered.” d. “Physician will be notified of error when he makes rounds tomorrow.” ANS: C Stating that the patient received morphine 10 mg instead of 5 mg is a factual statement to include on an incident report because it is objective and provides no interpretation or conjecture from the nurse. The remaining choices are incorrect statements that do not accurately reflect what occurred. The physician needs to be notified as soon as the patient has been assessed, not the following day. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 2. The nurse is documenting the care of a patient. Which entry would be characteristic of charting by exception (CBE) as a documentation method? a. The patient needed to be turned every hour because of increasing pain. b. The patient’s vital signs are stable. c. The patient’s gait was steady with assistance from physical therapy. d. There was no odor when the dressing was removed. ANS: A CBE allows the nurse to specify exceptions to normal nursing assessments efficiently without documenting the normal assessment data and reducing the amount of narrative writing in patient documentation. The emphasis is on recording abnormal findings and trends in clinical care. It is a shorthand method for documenting based on defined standards for normal nursing assessments and interventions. CBE simply involves completing a flow sheet that incorporates these standards, thus minimizing the need for lengthy narrative notes. Increasing pain would not be expected and would be outside the “normal” or “expected.” DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 3. The nurse is documenting on a patient with a respiratory problem. Which patient datum documented by the nurse is the least objective? a. Cool and dusky skin b. Low flow rate oxygen c. 30 breaths per minute d. Very restless and drowsy ANS: B TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N Low flow rate oxygen is the least objective datum and the datum most subject to interpretation because the quantity of oxygen is not as precise as “liters/minute” or the “percentage” of oxygen. The remaining options provide more verifiable data. DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 4. The nurse runs into a co-worker whose family friend is a patient on the unit. The co-worker asks about the friend’s health problems. Which is the correct response by the nurse? a. “Your friend told us to say nothing.” b. “Why don’t you ask your friend now?” c. “You know I can’t talk about the patients.” d. “Well, it was really a very difficult surgery.” ANS: C The nurse can’t talk about the co-worker’s friend or acknowledge the friend’s presence in the agency without breaching the friend’s right to privacy, so the nurse reminds the co-worker about confidentiality. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 5. The nurse is providing home care for a patient with an infection that is not improving. The patient refuses to see an infectious disease specialist. What should the nurse include in the documentation of the patient teaching provided? a. The discussion about the consequences of refusing to see a specialist and the patient’s response. b. The explanation that avoiding the specialist will most likely lead to a worse outcome. c. A hopeful explanation that this will most likely be the last medical specialist that the patient will need to see. d. The recommendation that the patient should discuss the decision with the family. ANS: A The nurse documents the discussion about the consequences of refusing to see a specialist and the patient’s response. Documenting the factual information presented about the risks of refusing treatment and the patient’s specific response to it (continued refusal to seek a specialist) are key pieces of information to include. The nurse should neither try to scare the patient into seeing the specialist nor provide false hope that only one consultation will be required. As long as the patient is competent to make a decision, the nurse must accept his or her choice. It is a requirement to document the facts surrounding that choice. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 6. At 0915 the nurse repeatedly instructs the patient to remain in bed. At 0930 the nurse enters the patient’s room, finds the patient on the floor, and hears the patient say, “I need pain medicine.” Which should the nurse do to document this event? a. Label the late entry using the time of 9:15 AM. b. Enclose the patient statement within quotations. c. Document completion of an incident report. TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N d. Record plan to administer pain medication. ANS: B The nurse documents patient statements in quotations to indicate the patient’s precise statement. The nurse should document instructions given at 0915 and verify any indications of patient comprehension. A second entry noted at 0930 documents finding patient on floor. Completion of an incidence report is not documented in the patient record since it is an internal evaluation report. Administration of medication is only documented after it occurs to make sure that the documentation is accurate in terms of time and patient response. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 7. A nurse passes by a computer screen that has patient information that can be seen by visitors. What is the appropriate action for the nurse to take at this time? a. Leave the computer screen alone. b. Try to find the nurse caring for this patient. c. Document this situation on an incident report. d. Close the computer screen. ANS: D All agency staff have a responsibility to maintain patient confidentiality and should not leave a computer displaying patient information open. The nurse should minimize or close the computer screen so patient information cannot be seen by visitors. He or she should talk with the nurse caring for this patient about what happened. Incident reports are only filed when a patient experiences an adverse event. This situation does not require an incident report. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 8. Nursing assistive personnel (NAP) finds a patient on the floor 30 minutes after the patient ambulated with physical therapy. What information should be charted by the NAP on the incident report? a. “Patient fell out of bed and landed on the floor.” b. “Patient found on floor. Upper side rails up. Bed in low position.” c. “Patient got dizzy and fell although ambulated with physical therapy earlier.” d. “Patient unfortunately slipped and fell.” ANS: B Documentation should state facts: “Patient found on floor. Upper side rails up. Bed in low position.” Only objective data with no interpretation can be documented by the NAP. The NAP does not evaluate the situation. Words such as “unfortunately” are never used in documentation. The NAP found the patient on the floor and did not see the patient slip and fall. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 9. An incident report is completed as a result of the pharmacy sending the wrong medication to the unit, even though the medication wasn’t administered. A student asks the nurse why this was needed. What response by the nurse is best? a. To make sure that the pharmacy was blamed for the error and not the nurse TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N b. To help the pharmacy identify risks and prevent this situation from occurring again c. To prevent the hospital from a medical malpractice suit d. To get the health care provider’s attention about ordering medications ANS: B The incident report is a risk-management tool that enables health care providers to identify risks within an agency, analyze them, and act to reduce the risks and evaluate the results. This is also true when deviations from standards occur and not only when actual adverse events happen. Alerting the pharmacy to this type of error should help prevent it from occurring again. There was no problem with the health care provider’s order, only with how it was filled. DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 10. The nursing staff have been using the SBAR format to structure communication for the past few months. Successful implementation of this system would be present if the nurse manager made which statement? a. “There are fewer omissions in patient care than before implementing this system.” b. “Fewer nurses are coming in late when they are scheduled to work.” c. “The medications are given on time now.” d. “The patient length of stay has decreased since last year.” ANS: A Noting fewer omissions in patient care would indicate successful implementation of the SBAR format. SBAR promotes the provision of safe, efficient, timely, and patient-centered communication. Staff timeliness, medication preparation, and length of patient stays are not affected by implementation of SBAR. DIF: Cognitive Level: Evaluating OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Evaluation 11. The nursing staff are assisting nursing students in learning military time for documenting. Instruction by the nurses has been effective if the students identify that which entry reflects 40 minutes after midnight? a. 0040 b. 1240 c. 0004 d. 0400 ANS: A 0040 is 12:40 AM. 1240 is 12:40 PM. 0004 is 12:04 AM. 0400 is 4:00 AM. DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Evaluation 12. The following is an example of what part of the SBAR communication mnemonic? “Her blood pressure has decreased from 140/90 to 100/50 and she vomited 400 mL of bright red blood.” a. S b. A c. R TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER TESTBANKWORLD.ORG N d. B ANS: A This is an example of S-Situation—what is happening at the present time. Background (explain the circumstances leading up to the situation). Assessment (what you think the problem is). Recommendation (what you would do to correct the problem). DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation MULTIPLE RESPONSE 1. Electronic health records (EHRs) can improve patient care. The following is an example of an alert in an EHR. (Select all that apply.) a. Notification of medication being overdue b. Change in patient’s blood pressure that exceeds parameters c. Order entered for a medication the patient is allergic to d. Routine lab orders e. Critical lab value ANS: A, B, C, E Alerts in EHRs notify nurses of critical changes in data that affect patient care and can be used to help nurses prioritize care. Overdue medications, critical lab values, and medication allergies are some of the examples of standard alerts. Alerts can also be tailored to patients to monitor for changes in their vital signs above certain parameters. When electronic health record alerts are used in the nurse’s practice, patient outcomes can be improved. DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 2. The Joint Commission standards require all patients admitted to a health care agency to have the following documented. (Select all that apply.) a. Self-care assessment b. Discharge planning needs c. Environment assessment d. Physical assessment e. Religious practices ANS: A, B, C, D Current TJC (2012) standards require that all patients who are admitted to a health care agency have an assessment of physical, psychosocial, environmental, self-care, patient education, and discharge planning needs. Religious practices are not a specific assessment although it could be included in the psychosocial assessment. DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation