Nclex questions for Fundamentals of Nursing with rationale Questions and Answers

Nclex questions for Fundamentals of Nursing with rationale Questions and Answers A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? 1) Phantom 2) Visceral 3) Deep somatic 4) Referred Answer: 3) Deep somatic Rationale: Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site. Which pain management task can the nurse safely delegate to nursing assistive personnel? 1) Asking about pain during vital signs 2) Evaluating the effectiveness of pain medication 3) Developing a plan of care involving nonpharmacologic interventions 4) Administering over-the-counter pain medications Answer: 1) Asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the registered nurse or licensed practical nurse. Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)? 1) Hepatitis B 2) Occasional alcohol use 3) Allergy to aspirin 4) Gastric irritation with bleeding Answer: 1) Hepatitis B Rationale: Even in recommended doses, acetaminophen can cause severe hepatotoxicity in patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly should also use acetaminophen cautiously. Those allergic to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) can use acetaminophen safely. Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it can be used for those with a history of gastric irritation and bleeding. Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain? 1) Assess the patient's incision. 2) Clarify the order with the prescriber. 3) Assess the patient's respiratory status. 4) Monitor the patient's heart rate. Answer: 3) Assess the patient's respiratory status. Rationale: Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's respiratory status because opioid analgesics can cause respiratory depression. It is not necessary to clarify the order with the physician because morphine 4 mg IV is an appropriate dose. It is not necessary to monitor the patient's heart rate. Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? 1) Caution the patient to limit the number of times he presses the dosing button. 2) Ask another nurse to double-check the setup before patient use. 3) Instruct the patient to administer a dose only when experiencing pain. 4) Provide clear, simple instructions for dosing if the patient is cognitively impaired. Answer: 2) Ask another nurse to double-check the setup before patient use. Rationale: As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient-controlled analgesia is contraindicated for those who are cognitively impaired. The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? 1) Immediately 2) In 10 minutes 3) In 15 minutes 4) In 60 minutes Answer: 4) In 60 minutes Rationale: Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effective almost immediately; however, codeine is not recommended for IV administration. Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis? 1) Ibuprofen (Motrin) 2) Celecoxib (Celebrex) 3) Aspirin (Ecotrin) 4) Indomethacin (Indocin) Answer: 3) Aspirin (Ecotrin) Rationale: Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation. A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? 1) Infection at the catheter insertion site 2) Side effect of the epidural analgesic 3) Epidural catheter migration 4) Spinal cord damage Answer: 3) Epidural catheter migration Rationale: The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural analgesics. These are common signs of catheter migration, not spinal cord damage. Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): 1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing 2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening 3) Heart rate was 76 before eating and is 60 after eating 4) Respiratory rate was 14 when standing and is 22 after walking Answer: 1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing 3) Heart rate was 76 before eating and is 60 after eating Rationale: The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise. The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has: 1) Crackles 2) Rhonchi 3) Stridor 4) Wheezes Answer: 3) Stridor Rationale: Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention. The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the: 1) Pulse deficit 2) Blood pressure 3) Apical pulse 4) Pulse pressure Answer: 2) Blood pressure Rationale: If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circulation. The pulse pressure is the difference between the systolic and diastolic pressures. Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is: 1) 118/68 when standing and 110/72 when lying down 2) 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing 3) 126/72 lying down and 133/80 when sitting, and reports shortness of breath 4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy Answer: 4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy Rationale: Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving to a standing position, with complaints of feeling dizzy and/or faint. A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client? 1) Axillary with an electronic thermometer 2) Oral with a glass thermometer 3) Rectal with an electronic thermometer 4) Tympanic with an infrared thermometer Answer: 3) Rectal with an electronic thermometer Rationale: The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data point for this client with hypothermia as it indicates the patient's baseline status and response to treatment. The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer used in the hospital setting. The accuracy of tympanic thermometers is debatable. Which of the following clients would have the most difficulty maintaining thermoregulation? 1) Young child playing soccer during the summer 2) Middle-aged adult snow skiing 3) Young adult playing golf on a hot day 4) Older adult raking leaves on a cold day Answer: 4) Older adult raking leaves on a cold day Rationale: Older adults have more difficulty maintaining body heat because of their slower metabolism, loss of subcutaneous fat, and decreased vasomotor control. Which of the following clients should have an apical pulse taken? A client who is: 1) Febrile and has a radial pulse of 100 bpm 2) A runner who has a radial pulse of 62 bpm 3) An infant with no history of cardiac defect 4) An elderly adult who is taking antianxiety medication Answer: 3) An infant with no history of cardiac defect Rationale: An apical pulse should be taken if the radial pulse is weak and/or irregular, if the rate is 60 or 100, if the patient is on cardiac medications, or when assessing children up to 3 years. It is difficult to palpate a peripheral pulse on infants and young children. Which situation requires intrapersonal communication? 1) Staff meetings 2) Positive self-talk 3) Shift report 4) Wound care committee meeting Answer: 2) Positive self-talk Rationale: The nurse engaging in positive self-talk is using intrapersonal communication—conscious internal dialogue. Staff meetings, shift report, and a committee meeting are all examples of group or interpersonal communication. The nurse suspects that a patient is being physically abused at home. What is the best environment in which to discuss the possibility of abusive events? 1) The patient's shared semiprivate room 2) The hallway outside the patient's room 3) An empty corner at the nurse's station 4) A conference room at the end of the hall Answer: 4) A conference room at the end of the hall Rationale: The best environment in which to discuss sensitive matters is a quiet room where conversation can occur in private, particularly when the space is nonthreatening. The patient might be distracted if conversation takes place in a room where others (e.g., patients and visitors) are present. The hallway outside the patient's room and the nurses' station are public areas and should not be used for private conversation. A patient is admitted to the medical surgical floor with a kidney infection. The nurse introduces herself to the patient and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship? The patient will be able to: 1) Describe how to operate the bed and call for the nurse. 2) Discuss communication patterns and roles within the family. 3) Openly express his concerns about the hospitalization. 4) State expectations related to discharge. Answer: 1) Describe how to operate the bed and call for the nurse. Rationale: This is the orientation phase of the relationship. The orientation phase begins when the nurse introduces herself to the patient and begins to gather data. In this phase, the nurse and patient are getting to know each other. As part of the orientation phase, the nurse will orient the patient to the hospital room and routines. In the preinteraction phase, the nurse gathers information about the patient before she meets him. Discussion of personal information, particularly if sensitive or complex, is suitable for the working phase of the nurse-patient interaction. The patient expressing feelings and concerns also occurs during the working phase. During the working phase, care is communicated, thoughts and feelings are expressed, and honest verbal and nonverbal communication occurs. Stating expectations related to discharge is most appropriate for the termination phase—the conclusion of the relationship. A local church organizes a group for people who are having difficulty coping with the death of a loved one. Which type of group has been organized? 1) Work-related social support group 2) Therapy group 3) Task group 4) Community committee Answer: 2) Therapy group Rationale: Therapy groups are designed to help individual members cope with issues, such as the death of a spouse, divorce, or motherhood. Work-related social support groups help members of a profession cope with work-associated stress. Task groups meet to accomplish a specified task. Community-based committees meet to discuss community issues. A mother comes to the emergency department after receiving a phone call informing her that her son was involved in a motor vehicle accident. When she approaches the triage desk, she frantically asks, "How is my son?" Which response by the nurse is best? 1) "He's being examined now; he's awake and talking. We'll take you to see him soon." 2) "Don't worry, I'm sure he'll be fine; we have an excellent trauma team caring for him." 3) "Everything will be okay; please take a seat and I'll check on him for you." 4) "Your son is strong and has youth on his side; I'm sure he'll be fine." Answer: 1) "He's being examined now; he's awake and talking. We'll take you to see him soon." Rationale: By telling the mother that her son is awake and talking and being examined by the doctor, the nurse provides accurate information and helps reduce the mother's anxiety. Responses such as "Don't worry, everything will be okay" and "I'm sure he'll be fine" offer false reassurance and fail to respect the mother's concern. During a presentation at a nursing staff meeting, the unit manager speaks very slowly with a monotone. She uses medical and technical terminology to convey her message. Dressed in business attire, the manager stands erect and smiles occasionally while speaking. Which elements of her approach are likely to cause the staff to lose interest in what she has to say? Select all answers that apply. 1) Slow speech 2) Monotone 3) Occasional smile 4) Formal dress Answer: 1) Slow speech 2) Monotone Rationale: Speaking slowly with a monotone can contribute to reduced attention as the listener can think faster than the speaker is speaking, and the monotone voice has an almost hypnotizing effect. Smiling improves personal interest and connection between the speaker and listener so should not cause a loss of interest. Wearing formal business attire would not directly detract from listeners' engagement in the speaker's message unless it was unusual enough to distract listeners; nothing in the situation above indicates that is so. Which factor(s) in the patient's past medical history place(s) him at risk for falling? Select all that apply. 1) Orthostatic hypotension 2) Appendectomy 3) Dizziness 4) Hyperthyroidism Answer: 1) Orthostatic hypotension 3) Dizziness Rationale: Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling. A history of right appendectomy and hyperthyroidism do not place that patient at risk for falling. The nurse is teaching a child and family about firearm safety. The nurse should instruct the child to take which step first if he sees a gun at a friend's house? 1) Leave the area. 2) Do not touch the gun. 3) Stop where he is. 4) Tell an adult. Answer: 3) Stop where he is. Rationale: The child should be instructed to stop where he is. This allows him to think about the next steps he has memorized. Next, he should avoid touching the gun, leave the area, and immediately go tell an adult. A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next? 1) Apply a vest restraint. 2) Move the patient to a quieter room. 3) Ask another nurse to care for the patient. 4) Provide comfort measures. Answer: 4) Provide comfort measures. Rationale: Patients sometimes become agitated because they are uncomfortable or in pain. Providing comfort measures may decrease agitation. If the patient continues to be agitated, the nurse should encourage a family member or friend to sit with the patient. Applying a physical restraint should be kept as a last resort for use only when less restrictive measures fail. The patient should be placed in a room near the nurses' station so he can be checked frequently if there is no one available to provide one-on-one supervision. A quieter room would probably not help. While teaching a health promotion group of adults, the nurse notices one person who is clutching his throat with both hands. What should the nurse do first? 1) Call 9-1-1. 2) Encourage the person to cough vigorously. 3) Ask, "Are you choking?" 4) Give five back blows. Answer: 3) Ask, "Are you choking?" Rationale: Clutching the throat is the universal sign of choking. The first action when you suspect airway obstruction is to ask, "Are you choking?" If the person indicates "yes," or if the person cannot cough, speak, or breathe, that indicates choking. You must first be certain the person is choking because you can cause harm when you perform the choking maneuver. You would not call 9-1-1, encourage coughing, or give five back blows until you first establish that the person is choking. The client appears to be giving the universal sign for choking, but the nurse must validate the client's meaning before acting. What should parents do to promote child safety in the home? 1) Attach the baby's pacifier to a ribbon so that it does not fall on the floor. 2) Give a 2-year-old whole grapes instead of popcorn for a snack. 3) Store firearms unloaded and out of sight in a location too high for the child to reach. 4) Install window guards; never leave a window wide open. Answer: 4) Install window guards; never leave a window wide open. Rationale: To prevent falls, install window guards and never leave a window wide open. A ribbon can become entangled around a small child's neck, causing asphyxiation. Young children can easily choke on a grape. Firearms should be unloaded, but stored in a locked cabinet. Children are curious and like to explore and climb. It would not be too difficult for a child to find a firearm stored, for example, on a high closet shelf. What is the leading cause of unintentional death for the entire U.S. population? 1) Motor vehicle accidents 2) Poisoning 3) Choking 4) Falls Answer: 1) Motor vehicle accidents Rationale: The leading causes of unintentional death for the total population, in this order, are automobile accidents, poisoning, falls, and drowning. Which change in hygiene practices may be necessary as the patient ages? 1) Brushing teeth twice a day 2) Bathing every other day 3) Decreasing moisturizer use 4) Increasing soap use Answer: 2) Bathing every other day Rationale: As a person ages, sebaceous glands become less active, causing skin to dry. Older people may find it necessary to bathe every 2 days, increase the use of moisturizers, and decrease soap use to prevent further drying of skin. Older adults should brush their teeth after every meal and at bedtime to prevent tooth decay. It is recommended that people of all ages brush their teeth at least twice a day, so that option does not represent a change in an older adult's hygiene practices. A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Choose all correct answers. 1) Male nursing assistant 2) Male licensed practical nurse 3) Female graduate nurse 4) Female registered nurse Answer: 3) Female graduate nurse 4) Female registered nurse Rationale: Orthodox Judaism prohibits personal care being provided by a member of the opposite sex. The patient who underwent a hysterectomy is female; therefore, out of respect for her religious beliefs, she should not be bathed by the male licensed practical nurse or nursing assistant. A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity? Answer: Dehydration Rationale: Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit, causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional status. The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who suffered a stroke 5 days ago. How should the nurse document this finding? 1) Maceration 2) Abrasion 3) Excoriation 4) Pressure ulcer Answer: 4) Pressure ulcer Rationale: The nurse should document a lesion caused by tissue compression and inadequate perfusion as a pressure ulcer. Abrasion, a rubbing away of the epidermal layer of skin, is commonly caused by shearing forces that occur when a patient moves or is moved in bed. Maceration is a softening of skin from prolonged moisture. Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? 1) Bathe the patient's entire body using 8 to 10 washcloths. 2) Assist the patient to a chair and provide bathing supplies. 3) Saturate a towel and blanket in a plastic bag, and then bathe the patient. 4) Assist the patient to the bathtub and provide a bath chair. Answer: 1) Bathe the patient's entire body using 8 to 10 washcloths. Rationale: A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient's body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub. For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? 1) Cover the mattress with a sheepskin. 2) Keep the linens wrinkle free. 3) Separate the skin folds with towels. 4) Apply petrolatum barrier creams. Answer: 2) Keep the linens wrinkle free. Rationale: Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence. A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? 1) Fever 2) Intact skin 3) Inflammation 4) Lethargy Answer: 2) Intact skin Rationale: Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection. A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? 1) A clean gown and gloves must be worn when in contact with the client. 2) Everyone who enters the room must wear a N-95 respirator mask. 3) All linen and trash must be marked as contaminated and send to biohazard waste. 4) Place the client in a room with a client with an upper respiratory infection. Answer: 1) A clean gown and gloves must be worn when in contact with the client. Rationale: A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections. A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One 1) admitted with unstable diabetes mellitus. 2) who underwent surgical repair of a perforated bowel. 3) with a stage 3 sacral pressure ulcer. 4) admitted with a urinary tract infection. Answer: 1) admitted with unstable diabetes mellitus. Rationale: The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer, or with a client who has a urinary tract infection. Which action demonstrates a break in sterile technique? 1) Remaining 1 foot away from nonsterile areas 2) Placing sterile items on the sterile field 3) Avoiding the border of the sterile drape 4) Reaching 1 foot over the sterile field Answer: 4) Reaching 1 foot over the sterile field Rationale: Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. A mother who breastfeeds her child passes on which antibody through breast milk? 1) IgA 2) IgE 3) IgG 4) IgM Answer: 3) IgG Rationale: The antibody IgG is passed to the child through the mother's breast milk during breastfeeding. IgA, IgE, and IgM are produced by the child's body after exposure to an antigen. What is the rationale for hand washing? Hand washing is expected to remove: 1) transient flora from the skin. 2) resident flora from the skin. 3) all microorganisms from the skin. 4) media for bacterial growth. Answer: 1) transient flora from the skin. Rationale: There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans, microbes must be able to use the body's precise balance of food, moisture, nutrients, electrolytes, pH, temperature, and light. Food, water, and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms, except perhaps briefly when an antiseptic agent is used for cleansing. Which of the following incidents requires the nurse to complete an occurrence report? 1) Medication given 30 minutes after scheduled dose time 2) Patient's dentures lost after transfer 3) Worn electrical cord discovered on an IV infusion pump 4) Prescription without the route of administration Answer: 2) Patient's dentures lost after transfer Rationale: You would need to complete an occurrence report if you suspect your patient's personal items to be lost or stolen. A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider's order is missing information; an occurrence report is not necessary. The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: 1) Separates the health record according to discipline 2) Organizes documentation around the patient's problems 3) Highlights the patient's concerns, problems, and strengths 4) Is designed to streamline documentation Answer: 1) Separates the health record according to discipline Rationale: In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient's problems. Focus® charting highlights the patient's concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation. When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO Answer: 3) NKA Rationale: The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth. The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: 1) Are comprehensive charting forms that integrate assessments and nursing actions 2) Contain only graphic information, such as I&O, vital signs, and medication administration 3) Are used to record routine aspects of care; they do not contain assessment data 4) Contain vital data collected upon admission, which can be compared with newly collected data Answer: 1) Are comprehensive charting forms that integrate assessments and nursing actions Rationale: Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information. At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? 1) Complete an occurrence report before leaving. 2) Do nothing; the next nurse will document it was done. 3) Write the note of the dressing change into an earlier note. 4) Make a late entry as an addition to the narrative notes. Answer: 4) Make a late entry as an addition to the narrative notes. Rationale: If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed. The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? 1) It includes organizational reports of unusual occurrences that are not part of the client's record. 2) This type of system consists of combined documentation and daily care plans. 3) It improves interdisciplinary collaboration that improves efficiency in procedures. 4) This type of system tracks medication administration and usage over 24 hours. Answer: 3) It improves interdisciplinary collaboration that improves efficiency in procedures. Rationale: The EHR has several benefits for use, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client's record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage. In the United States, the first programs for training nurses were affiliated with: 1) The military 2) General hospitals 3) Civil service 4) Religious orders Answer: 4) Religious orders Rationale: When the Civil War broke out, the Army used nurses who had already been trained in religious orders. Although the Army did provide some training, it occurred later than in the religious orders. Although nurses were trained in hospitals, the training and the hospitals were affiliated with religious orders. Civil service was not mentioned in Chapter 1 and was not a factor in the early 1800s. Nursing started with religious orders. The Hindu faith was the first to write about nursing. In the United States, all training for nurses was affiliated with religious orders until after the Civil War. Which of the following is/are an example(s) of a health restoration activity? Select all that apply. 1) Administering an antibiotic every day 2) Teaching the importance of hand washing 3) Assessing a client's surgical incision 4) Advising a woman to get an annual mammogram after age 50 years Answer: 1) Administering an antibiotic every day 3) Assessing a client's surgical incision Rationale: Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client's surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness.