NUR 155 EXAM 1 (UNITS 1 & 2) WITH
CORRECT SOLUTIONS
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-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-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-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-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-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
3. KCl 15 mL given orally for K+ level of 2.9
4. Regular insulin 10.0 u given SQ for capillary blood glucose of 180
5. Ambien 5 mg given orally at bedtime per request - ANSWER-Answer: 2, 3, and 5
Rationale: Option 1: "MS" is on the "Do Not Use"
list—the nurse needs to write out morphine sulfate. Option 4 has three errors—should
not have a trailing zero after the decimal point; "u" and "SQ" are on the "Do Not Use"
list.
A 74-year-old female is brought to the emergency department c/o right hip pain. The
right leg is shorter than the left and is externally rotated. During inspection, the nurse
observes what appears to be cigarette burns on the client's inner thighs. Which of the
following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs bilaterally
2. Several burned areas on both of the client's inner thighs
3. Multiple lesions on inner thighs possibly related to elder
abuse
4. Several lesions on inner thighs similar to cigarette burns - ANSWER-Answer: 1
Rationale: Option 1 is the most specific, non-assuming, and nonjudgmental charting.
Option 2 could be more specific by describing the lesions and not calling them "burns."
Option 3 is making
a judgment of elder abuse, and option 4 is also making an assumption that the lesions
are from cigarette burns
Which charting rule(s) will keep the nurse legally safe? Select all that apply.
1. Use military time.
2. Document worries or concerns expressed by the client.
3. Perform most of the charting at the end of the shift.
CORRECT SOLUTIONS
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-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-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-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-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-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
3. KCl 15 mL given orally for K+ level of 2.9
4. Regular insulin 10.0 u given SQ for capillary blood glucose of 180
5. Ambien 5 mg given orally at bedtime per request - ANSWER-Answer: 2, 3, and 5
Rationale: Option 1: "MS" is on the "Do Not Use"
list—the nurse needs to write out morphine sulfate. Option 4 has three errors—should
not have a trailing zero after the decimal point; "u" and "SQ" are on the "Do Not Use"
list.
A 74-year-old female is brought to the emergency department c/o right hip pain. The
right leg is shorter than the left and is externally rotated. During inspection, the nurse
observes what appears to be cigarette burns on the client's inner thighs. Which of the
following is the most appropriate documentation?
1. Six round skin lesions partially healed, on the inner thighs bilaterally
2. Several burned areas on both of the client's inner thighs
3. Multiple lesions on inner thighs possibly related to elder
abuse
4. Several lesions on inner thighs similar to cigarette burns - ANSWER-Answer: 1
Rationale: Option 1 is the most specific, non-assuming, and nonjudgmental charting.
Option 2 could be more specific by describing the lesions and not calling them "burns."
Option 3 is making
a judgment of elder abuse, and option 4 is also making an assumption that the lesions
are from cigarette burns
Which charting rule(s) will keep the nurse legally safe? Select all that apply.
1. Use military time.
2. Document worries or concerns expressed by the client.
3. Perform most of the charting at the end of the shift.
