Which action by a nurse ensures confidentiality of a client’s computer record?
The nurse logs on to the client’s file and leaves the computer to answer the client’s call light.
The nurse shares her computer password.
The nurse closes a client’s computer file and logs off.
The nurse leaves client computer worksheets at the computer workstation.
The case management model using critical pathways would be appropriate for a client with which diagnosis?
Myocardial infarction (heart attack)
Myocardial infarction, diabetes, hypertension
Diabetes, hypertension, an infected foot ulcer, senile
After making a documentation error, which action should the nurse take?
Use correcting liquid to cover the mistake and make a new entry.
Draw a line through it and write error above the entry.
Draw a line through it and write mistaken entry above it.
Draw a line through the mistake and write mistaken entry with initials above it.
Which charting entry would be the most defensible in court?
Client fell out of bed
Client drunk on admission
Large bruise on left thigh
Notified Dr. Jones of BP of 90/40
The client’s VS are WNL. He has BRP and he receives his pain pill PRN. His nutrition is DAT. Interpret the commonly used abbreviations. (write interpretations on paper, default answer will be a, answer will be given at the end of test)
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?
Ask the client about past blood pressure ranges.
Review the graphic record on the client’s record.
Examine the medication record for antihypertensive medications.
Review the progress notes included in the client’s record.
A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse represents effective nursing practice? Select all that apply
Provides the medical diagnosis or reason for admission
States the time the client last received pain medication
Speaks loudly when giving report
States priorities of care that are due shortly after the report
Reports on number of visitors for each client
Which charting entries are written correctly? Select all that apply.
MS 5 gr given IV for c/o abdominal pain
Lanoxin 0.25 mg given orally per Dr. Smith’s stat order
KCl 15 mL given orally for K+ level of 2.9
Regular insulin 10.0 u given SQ for capillary blood glucose of 180
Ambien 5 mg given orally at bedtime per request
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 whatappears to be cigarette burns on the client’s inner thighs. Which of the following is the most appropriate documentation?
Six round skin lesions partially healed, on the inner thighs bilaterally
Several burned areas on both of the client’s inner thighs
Multiple lesions on inner thighs possibly related to elder abuse
Several lesions on inner thighs similar to cigarette burns
Which charting rule(s) will keep the nurse legally safe? Select all that apply.
Use military time
Document worries or concerns expressed by the client.
Perform most of the charting at the end of the shift.
Record only information that pertains to the client’s health problems.