Which identifies accurate nursing documentation?
Select all that apply
a. The client slept through the night
b. Abdominal wound dressing is dry and
... [Show More] intact without drainage
c. The client seemed angry when awakened for vital sign measurement
d. the client appears to become anxious when it is time for respiratory treatments.
e. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
A,B,E
Only use factual information. (seems and appears are vague non-factual terms)
The LPN enters a client's room and finds the client lying on the bathroom floor. The LPN calls the RN, who checks the client thoroughly and then assist the client back into bed. The LPN completes and incident report, and the nursing supervisor and PCP are notified of the incident. Which is the next nursing action regarding the incident?
a. Place the incident report in the client's chart
b. make a copy of the incident report for the PCP
c. document a complete entry in the client's record concerning the incident.
d. document in the client's record that an incident report has been completed
C.
The incident report is confidential and it should not be copied or placed in the chart.
An unconscious patient, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the patient's life. With regard to informed consent for the surgical procedure, which is the BEST action?
a. call the nursing supervisor to initiate a court order for the surgical procedure
b. try calling the patients' spouse to obtain telephone consent before the surgical procedure
c. ask the friend who accompanied the patient to the emergency department to sign the consent form
d. transport the client to the operating department immediately without obtaining an informed consent.
D.
There are two instances in which an informed consent of an adult patient is not needed. 1) When an emergency is present and delaying tx would result in injury or death. 2) when the patient waives the right to give an informed consent
A nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the children. The nurse has never worked in the pediatric unit. Which of the following is the appropriate nursing action?
a. Call the hospital lawyer
b. call the nursing supervisor
c. refuse to float to the pediatric unit
d. report to the pediatric unit and identify task that can be safely performed
D.
Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area
The nurse enters a patient's room and notes that the patient's lawyer is present and the patient is preparing a living will. The living will requires that the patient signature is witnessed, and the patient asks the nurse to witness the signature. Which is the appropriate nursing action?
a. decline to sign the will
b. sign the will as a witness to the signature only
c. call the hospital lawyer before signing the will
d. sign the will, clearly identifying credentials and employment agency.
A.
Nurses are prohibited form being a witness
The nurse finds the patient lying on the floor. The nurse calls the RN, who checks the patient and then calls the nursing supervisor and the PCP to inform them of the occurrence. The nurse completes the incident report for which purpose?
a. providing patient with necessary stabilizing treatments
b. a method of promoting quality care and risk management
c. determining the effectiveness of interventions in relation to outcomes
d. the appropriate method of reporting to local, state, and federal agencies.
B
Documentation allows the nurse and administration to review the quality of care and determine any potential risks present
The nurse observes that a patient received pan medication 1 hr ago from another nurse, but the patient still has severe pain. The nurse previously observed the same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action?
a. report the information to the police
b. call the impaired nurse organization
c. talk with the nurse who gave the medication
d. report the information to the nursing supervisor
D.
The suspicion needs to be reported to the nursing supervisor who will then report to the board of nursing
The patient has died and the nurse ask a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?
a. Show acceptance of feelings
b. provide information needed for decision making
c. suggest a referral to a mental health professional
d. remain with the family member without discussing funeral arrangements
D
The family member is exhibiting the first stage of denial and the nurse should remain with the family member. Option A is an appropriate intervention for the acceptance or reorganization stage.
A nurse lawyer provides an education session to the nursing staff regarding patient rights with emphasis on invasion of patient rights. The nurse lawyer ask a staff nurse to identify a situation that represent an example of invasion of patients' privacy. Which situation, if identified by the student, indicates an understanding of a violation of client rights?
a. Threatening to place a patient in retraints
b. performing a surgical procedure without consent
c. taking photographs of the patient without consent
d. telling the patient that he or she cannot leave the hospital
C. [Show Less]