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A nurse is preparing to document a patient’s pain level, which the patient rates as 10 out of 10. What is the nurse's priority action?
A nurse is preparing to document a patient’s pain level, which the patient rates as 10 out of 10. What is the nurse's priority action?
When documenting in a patient’s electronic health record (EHR), which of the following practices should a nurse follow to ensure accuracy?
When documenting in a patient’s electronic health record (EHR), which of the following practices should a nurse follow to ensure accuracy?
According to HIPAA regulations, what is a nurse required to do to maintain patient confidentiality?
According to HIPAA regulations, what is a nurse required to do to maintain patient confidentiality?
Which statement about the legal guidelines for documentation is correct?
Which statement about the legal guidelines for documentation is correct?
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A nurse is documenting a patient’s statement regarding their health condition. How should the nurse accurately record the patient’s words?
A nurse is documenting a patient’s statement regarding their health condition. How should the nurse accurately record the patient’s words?
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A nurse enters a patient’s room to find the patient unresponsive. The nurse does not perform CPR because the patient has a Do Not Resuscitate (DNR) order. Which ethical principle is the nurse upholding?
A nurse enters a patient’s room to find the patient unresponsive. The nurse does not perform CPR because the patient has a Do Not Resuscitate (DNR) order. Which ethical principle is the nurse upholding?
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A nurse threatens to withhold pain medication if a patient does not stop yelling. This is an example of:
A nurse threatens to withhold pain medication if a patient does not stop yelling. This is an example of:
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A nurse accidentally administers the wrong dose of medication, and the patient experiences a negative reaction. Which legal concept does this situation represent?
A nurse accidentally administers the wrong dose of medication, and the patient experiences a negative reaction. Which legal concept does this situation represent?
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According to the American Nurses Association (ANA) Code of Ethics, which of the following actions demonstrates advocacy for the patient?
According to the American Nurses Association (ANA) Code of Ethics, which of the following actions demonstrates advocacy for the patient?
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Which of the following is a legal requirement for a nurse who suspects elder abuse?
Which of the following is a legal requirement for a nurse who suspects elder abuse?
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A nurse charts that a patient was “uncooperative and rude” during a dressing change. What documentation error does this represent?
A nurse charts that a patient was “uncooperative and rude” during a dressing change. What documentation error does this represent?
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A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN). Which of the following tasks is the RN permitted to delegate?
A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN). Which of the following tasks is the RN permitted to delegate?
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Which of the following is a component of effective delegation according to the Five Rights of Delegation?
Which of the following is a component of effective delegation according to the Five Rights of Delegation?
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An RN is working with a UAP on a busy unit. Which of the following tasks can the RN delegate to the UAP?
An RN is working with a UAP on a busy unit. Which of the following tasks can the RN delegate to the UAP?
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The RN is hesitant to delegate tasks due to insecurity and fear of liability. Which of the following would help the RN overcome delegation insecurity?
The RN is hesitant to delegate tasks due to insecurity and fear of liability. Which of the following would help the RN overcome delegation insecurity?
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When delegating tasks, which patient should the RN assign to the unlicensed assistive personnel (UAP)?
When delegating tasks, which patient should the RN assign to the unlicensed assistive personnel (UAP)?
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The RN is responsible for delegating tasks to a UAP. According to the scope of practice, which of the following statements is true regarding delegation?
The RN is responsible for delegating tasks to a UAP. According to the scope of practice, which of the following statements is true regarding delegation?
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A nurse is evaluating a patient's response to an intervention. Which of the following is the best action for the nurse to take when a goal has not been fully achieved?
A nurse is evaluating a patient's response to an intervention. Which of the following is the best action for the nurse to take when a goal has not been fully achieved?
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A nurse is assessing a patient’s response to pain medication 45 minutes after administration. Which phase of the nursing process is the nurse engaging in?
A nurse is assessing a patient’s response to pain medication 45 minutes after administration. Which phase of the nursing process is the nurse engaging in?
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When evaluating patient outcomes, which of the following criteria is most important for the nurse to use?
When evaluating patient outcomes, which of the following criteria is most important for the nurse to use?
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After revising a patient’s care plan, the nurse determines that additional time is needed for the patient to meet the revised goals. Which step should the nurse take next?
After revising a patient’s care plan, the nurse determines that additional time is needed for the patient to meet the revised goals. Which step should the nurse take next?
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During evaluation, the nurse collaborates with the patient and family to determine if the patient has met the set goals. Which of the following is a key benefit of this collaboration?
During evaluation, the nurse collaborates with the patient and family to determine if the patient has met the set goals. Which of the following is a key benefit of this collaboration?
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A nurse is reviewing a patient’s progress and finds that the patient has not demonstrated the ability to change a wound dressing due to severe arthritis. What is the nurse's best course of action?
A nurse is reviewing a patient’s progress and finds that the patient has not demonstrated the ability to change a wound dressing due to severe arthritis. What is the nurse's best course of action?
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A nurse is setting goals for a patient who is recovering from surgery. Which of the following characteristics must these goals have to be effective?
A nurse is setting goals for a patient who is recovering from surgery. Which of the following characteristics must these goals have to be effective?
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The nurse is setting a short-term goal for a patient. Which of the following is the best example of a short-term goal?
The nurse is setting a short-term goal for a patient. Which of the following is the best example of a short-term goal?
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Which of the following is an example of a SMART goal for a patient with hypertension?
Which of the following is an example of a SMART goal for a patient with hypertension?
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A nurse is planning interventions for a patient with diabetes. Which of the following is an example of a nurse-initiated (independent) intervention?
A nurse is planning interventions for a patient with diabetes. Which of the following is an example of a nurse-initiated (independent) intervention?
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When prioritizing a patient’s nursing diagnoses, which of the following should the nurse address first?
When prioritizing a patient’s nursing diagnoses, which of the following should the nurse address first?
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The nurse is collaborating with other healthcare professionals to develop a discharge plan for a patient. Which of the following is an essential component of discharge planning?
The nurse is collaborating with other healthcare professionals to develop a discharge plan for a patient. Which of the following is an essential component of discharge planning?
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A nurse is implementing a care plan for a patient. Which of the following is an example of a direct care intervention?
A nurse is implementing a care plan for a patient. Which of the following is an example of a direct care intervention?
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When performing nursing interventions, which of the following is an example of a nurse-initiated (independent) intervention?
When performing nursing interventions, which of the following is an example of a nurse-initiated (independent) intervention?
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During the implementation phase of the nursing process, the nurse is primarily focused on:
During the implementation phase of the nursing process, the nurse is primarily focused on:
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The nurse is about to perform an indirect intervention. Which of the following is an example of an indirect intervention?
The nurse is about to perform an indirect intervention. Which of the following is an example of an indirect intervention?
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A nurse is working with a patient to achieve the care plan's outcomes. Which of the following must the nurse do during the implementation of care?
A nurse is working with a patient to achieve the care plan's outcomes. Which of the following must the nurse do during the implementation of care?
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Which of the following should the nurse consider while implementing interventions for a patient?
Which of the following should the nurse consider while implementing interventions for a patient?
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A nurse is documenting a patient’s condition. Which of the following should the nurse include in the patient’s chart?
A nurse is documenting a patient’s condition. Which of the following should the nurse include in the patient’s chart?
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Which action by the nurse violates documentation standards?
Which action by the nurse violates documentation standards?
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A nurse is charting in a patient’s medical record. Which of the following is an appropriate documentation practice?
A nurse is charting in a patient’s medical record. Which of the following is an appropriate documentation practice?
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A physician asks a nurse to change a patient’s chart entry from yesterday. What is the best response by the nurse?
A physician asks a nurse to change a patient’s chart entry from yesterday. What is the best response by the nurse?
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A nurse realizes that an entry in the patient’s chart is incorrect. What is the best action for the nurse to take?
A nurse realizes that an entry in the patient’s chart is incorrect. What is the best action for the nurse to take?
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Which of the following actions is a don’t in documentation practices?
Which of the following actions is a don’t in documentation practices?
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Study Notes
Pain Level Documentation
- If a patient rates their pain as 10 out of 10, the nurse's priority action is to immediately assess the patient and provide pain relief.
- The nurse should document the patient’s pain level using a standardized pain assessment tool, noting the location, intensity, and quality of pain.
- The nurse should report the severe pain and initiate interventions to manage the symptoms.
Electronic Health Record (EHR) Documentation
- To ensure accuracy, the nurse must be diligent about maintaining the EHR, including:
- Using the correct patient record
- Documenting only what they have personally observed or assessed
- Verifying all entries before saving
- Using proper grammar and spelling
- Avoiding jargon or abbreviations not universally understood
HIPAA Regulations
- To maintain patient confidentiality, the nurse must:
- Access only the information they need for their care responsibilities.
- Avoid sharing patient information with unauthorized personnel.
- Use strong passwords to protect their computer access.
Legal Guidelines for Documentation
- The nurse's documentation, including all entries in the patient’s medical record, must accurately reflect the care provided:
- Use clear, concise, and complete language.
- Avoid using subjective terms or judgments.
- Document the date and time of all entries.
- Sign all entries with the nurse's full name and credentials.
- Correct errors appropriately.
Documenting Patient Statements
- To accurately record a patient’s words, the nurse should use quotation marks and document the exact statement verbatim.
Ethical Principles
- By honoring a Do Not Resuscitate (DNR) order, the nurse is upholding the principle of autonomy by respecting the patient's right to make decisions about their healthcare.
Medical Malpractice
- Threatening to withhold pain medication is a form of coercion and violates ethical and legal guidelines.
- Administering the wrong dose of medication, resulting in a negative patient reaction, represents a form of negligence and can lead to legal action.
Advocacy
- According to the ANA Code of Ethics, advocacy for the patient can be demonstrated through many actions like:
- Directly advocating for the patient's preferences and needs.
- Protecting the patient's rights to informed consent.
- Reporting any suspicions of abuse or neglect.
Elder Abuse Reporting
- A nurse who suspects elder abuse is legally required to report it to the appropriate authorities.
Documentation Errors
- Charting a patient as “uncooperative and rude” represents an subjective and opinionated documentation error.
- It is essential to use objective language when documenting patient behavior and avoid using subjective judgments.
Nurse Delegation
- An RN is permitted to delegate tasks that are within the scope of practice of an LPN.
- An RN should not delegate tasks that require independent nursing judgment.
Effective Delegation
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The Five Rights of Delegation include:
- Right Task: The task is appropriate for the delegate's level of education and training.
- Right Circumstances: The patient's condition is stable and appropriate for delegation.
- Right Person: The delegate is qualified and competent to perform the task.
- Right Direction/Communication: The RN provides clear instructions about the task, including expected outcomes, timeframes, and any necessary precautions.
- Right Supervision: The RN monitors the delegate's performance and provides feedback.
RN and UAP Delegation
- An RN can delegate tasks like:
- Vital signs measurement
- Basic hygiene care
- Routine patient positioning
Delegation Insecurity
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To overcome delegation insecurity, the RN can:
- Seek mentorship and guidance from experienced nurses.
- Refine their delegation skills through training programs.
- Practice delegation in low-risk situations and gradually increase complexity.
- Consult with other RNs or supervisors for reassurance.
Delegation Patient Assignments
- For the safety of the patient, the RN should assign the patient who requires the most complex nursing care to the LPN.
Delegation Scope of Practice
- The RN is ultimately responsible for ensuring that the tasks delegated to a UAP are within the scope of their practice.
Goal Evaluation
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When a patient outcome has not been fully achieved, the nurse should:
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Reassess the patient's status and identify any barriers to goal achievement.
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Modify the care plan by adjusting the interventions or setting new goals.
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Nursing Process - Evaluation
- Assessing a patient's response to pain medication 45 minutes after administration is an example of the evaluation phase of the nursing process.
Evaluation Criteria
- The most important criterion for evaluating patient outcomes is the patient's progress toward achieving desired outcomes.
Goal Revision
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When a patient needs additional time to meet revised goals, the nurse should:
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Extend the time frame for achieving the goals.
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Reassess the patient's progress regularly.
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Collaboration in Evaluation
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Collaborating with patients and families during evaluation:
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Enhances the patient's understanding of their care plan.
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Promotes a sense of partnership and ownership in the goals.
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Non-Achievement of Goal
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If a patient has not demonstrated the ability to change a wound dressing due to severe arthritis, the nurse should:
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Modify the care plan by:
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Providing education to the patient and caregivers on wound care.
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Identifying alternative methods for wound dressing changes.
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Incorporating assistive devices as needed.
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Effective Goals
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For a patient recovering from surgery, the goals must be:
- Specific
- Measurable
- Achievable
- Relevant
- Time-bound
Short-Term Goal Examples
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An example of a short-term goal for a patient is:
- "Patient will ambulate independently 20 feet by the end of the shift."
SMART Goal
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A SMART goal for a patient with hypertension is:
- "Patient will lower their blood pressure to 130/80 within 4 weeks by following a low-sodium diet and taking prescribed medication.”
Nurse-Initiated Intervention
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A nurse-initiated intervention for a patient with diabetes:
- "Educate the patient on blood glucose monitoring techniques."
Prioritizing Nursing Diagnoses
- When prioritizing nursing diagnoses, the nurse should address the most urgent and life-threatening diagnoses first.
Discharge Plan
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An essential component of discharge planning includes:
- Collaborating with the patient and family to develop a plan that addresses their individual needs.
Direct Care Intervention
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An example of a direct care intervention is:
- Administering medications to the patient.
Nurse-Initiated Intervention (Independent)
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An example of a nurse-initiated intervention is:
- Performing deep-breathing exercises with a patient to promote lung expansion.
Implementation Phase
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During implementation, the nurse is focused on:
- Carrying out the planned nursing interventions.
- Monitoring the patient's response to interventions.
- Communicating with the healthcare team about patient progress.
Indirect Intervention
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An example of an indirect intervention is:
- Consulting with a social worker to help a patient with financial needs.
Implementing Interventions
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During intervention implementation, the nurse must:
- Assess the patient's response to the planned interventions.
- Evaluate the effectiveness of the interventions.
- Modify the care plan as needed based on the patient's response.
Considerations in Implementing Interventions
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When implementing interventions, the nurse should consider:
- Safety of the patient
- Patient preferences
- Availability of resources
- Time constraints
Documentation in Patient’s Chart
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The nurse should include these points in the patient’s chart:
- All assessments, interventions, and patient responses.
- Medication administration records.
- Any changes in the patient’s condition.
Violating Documentation Standards
- A nurse leaving a chart open and unattended violates documentation standards, as it puts patient information at risk for unauthorized access.
Documentation Practice
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An appropriate documentation practice includes:
- Using the correct patient record and documenting only what they have personally observed or assessed.
Chart Entry Modification
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If a physician asks a nurse to change a patient's chart entry, the nurse should:
- Inform the physician that only the original author can change the entry.
Correcting Documentation Errors
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To correct a documentation error, the nurse should:
- Draw a single line through the incorrect entry, initial and date it.
- Document the correct information beneath the line, initial and date it.
- Never erase or obscure original entries.
Documentation Don’t
- A nurse never leaving a chart open and unattended violates documentation standards.
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Description
This quiz assesses the priority actions a nurse should take when documenting a patient's extreme pain level, rated as 10 out of 10. Understanding proper pain management protocols is crucial for effective nursing care and patient safety.
