Exam (elaborations)
2024 NUR 155 VERIFIED EXAM 1 (UNITS 1 & 2) WITH 100% CORRECT ANSWERS
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2024 NUR 155 VERIFIED EXAM 1 (UNITS 1 & 2) WITH 100% CORRECT ANSWERS
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2024 NUR 155 VERIFIED EXAM 1(UNITS 1 & 2) WITH 100%
CORRECT ANSWERS
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.
- CORRECT-ANSWERSAnswer: 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 -
CORRECT-ANSWERSAnswer: 1
Rationale: Critical pathways work best for clients with one diagnosis.
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. - CORRECT-
ANSWERSAnswer: 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 - CORRECT-
ANSWERSAnswer: 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 - CORRECT-
ANSWERSAnswer: 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
Which charting rule(s) will keep the nurse legally safe? Select all that apply.
1. Use military time.
2. Document worries or concerns expressed by the client.
3. Perform most of the charting at the end of the shift.
4. Record only information that pertains to the client's health problems. -
CORRECT-ANSWERSAnswer: 1, 2, and 4
Rationale: Military time is commonly used; documenting worries or concerns
provides clues to other nurses; gossip, unprofessional comments or
thoughts, or personnel issues should not
be recorded in the client's chart. Option 3 is incorrect because charting
should be done as events occur. Waiting until the end of the shift
increases the chance of forgetting something.
Which charting entry would be the most defensible in court?
1. Client fell out of bed
2. Client drunk on admission
3. Large bruise on left thigh
4. Notified Dr. Jones of BP of 90/40 - CORRECT-ANSWERSAnswer: 4
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