VNSG 1304 Foundations of Nursing Chapter 7 & 8 NCLEX Questions Questions and Answers 2024/2025

The nurse has misplaced her computer password. She asks if she can borrow your "just for a moment" to view patient data and promises she will not document anything. You best course of action is:  Inform her to contact the IT Department to obtain a new password. (The computer password is your legal signature and must not be shared under any circumstance. Even viewing the information together would be an invasion of privacy, because you have no justification for viewing patient information other than that of your assigned patient. The nurse needs to get a new password from IT.) Which is the most precise example of appropriate documentation?  "Ambulated 2x during shift, 50 ft with assistance of one. Preactivity vs: 85, 18, 110/70; postactivity vs: 95, 22, 120/76." (This choice represents the most precise documentation of the choices offered. Choice 1 uses conclusions reached by the author, not the data that led to the conclusions. Choices 2 and 4 could be improved by defining and providing data as to why the author concluded that the patient tolerated the procedure or activity well.) Patients frequently request copies of their medical records. You understand that:  Only people directly associated with the care of that patient have legal access to the information in the medical record. The medical record is the property of the hospital or agency, not of the patient. The patient does have right of access to the medical record but must follow the proper procedures for obtaining these. (The medical record is the property of the health facility or agency, not of the patient or primary care provider. Only those health professionals caring directly for the patient, or those involved in research or teaching, should have access to the medical record.) When documenting, it is wise to always: 2 0 2 4 /2025 | © copyright | This work may not be copied for profit gain Excel! 1 | P a g e | G r a d e A + | 2 0 24 / 2 0 2 5  Ensure you are on the right medical record. (Making certain you are in the correct medical record (or screen and date) is critical for accurate documentation. Visitor names need not be documented, and be careful to use only acronyms approved by your facility. Sign and date any paper documentation as per facility policy; full name, date, and time are not necessary on every sheet.) When a patient's medical record is needed as evidence for a legal action, you are aware that the record is the property of:  The health care agency (The medical record is the property of the health facility or agency, not of the patient or primary care provider.) The assumption in charting by exception is that:  Unless otherwise documented, all standards have been met. (Charting by exception is based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented.) An advantage of electronic medical records is that:  It can save nursing time compared with writing out notes. (Once an EHR system is up and running smoothly, documentation time by nurses can be minimized, thus saving nurse time and agency money. Computers can break down, however, which is why choice 1 is incorrect. Security issues do exist with computers (choice 2), and facilities must go to great lengths to ensure patient privacy. Others may be able to see what a nurse is documenting if the nurse is not careful (choice 3), but this is a disadvantage, not an advantage.) When documenting the patient's condition and nursing care, the nurse records:  Interventions performed and patient response. Patient statements and behaviors that are observed. Clinical data measurements. (Interventions performed and relevant data, including patient statements and response, are important to document in regard to nursing care rendered to a patient. Activities and goals (choices 1 and 2) are more appropriately documented in the nursing care plan.) The nurse is using therapeutic communication to establish rapport. The nurse says, "How are you feeling the morning?". Which nonverbal behavior is congruent with the nurse's verbal question? 2 0 2 4 /2025 | © copyright | This work may not be copied for profit gain Excel! 1 | P a g e | G r a d e A + | 2 0 24 / 2 0 2 5  Looks at patient; stands with relaxed body position. (A relaxed body position nonverbally communicates therapeutic communication and encourages the patient to provide an honest answer. Arms folded across one's chest (choice 2) communicates negative body language and is a barrier to communication, as is multitasking (choices 3 and 4).) A patient expresses serious concerns about the outcomes of a scheduled surgical procedure. Which response indicates that the nurse is using active listening while the patient is speaking?  Nurse nods his head. (The nurse nodding his head in this situation nonverbally conveys that he understood what the patient said and encourages further elaboration. It is an effective use of silence. Choice 1 offers false reassurance; choice 2 is a communication block (changing the subject); and choice 3 makes an assumption (fear) and possibly oversimplifies the patient's concerns.) What is a correct beginning for an ISBAR-R communication with a physician?  "Dr. Thomas, this is Patricia, the nurse caring for your patient, Mr. Leo." (The I in ISBARR stands for introduction, which introduces the speaker to the listener before giving information or asking for recommendations.) The nurse enters the patient room to perform patient education. Which nonverbal communication by the patient is an indication that the education time should be rescheduled?  Wringing hands while