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NUR 155 Exam 1 (Units 1 & 2) TEST GUIDE WITH COMPLETE SOLUTION
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NUR 155 Exam 1 (Units 1 & 2) TEST GUIDE WITH COMPLETE SOLUTION
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NUR 155 Exam 1 (Units 1 & 2) TEST GUIDEWITH COMPLETE SOLUTION
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. - ANS
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 - ANS 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 - ANS
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. - ANS 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. - ANS 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 - ANS 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 - ANS 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
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