Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?
A. Use objective terminology when documenting
This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
B. Wait at least 12 hours to report the occurrence
This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
C. Omit the name of the individuals involved
This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
D. Document completion of the report in the client’s medical record
This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.
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Full Explanation
Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.
Similar Questions
A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?
A. Airway protection
This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
B. Stabilizing cardiac arrhythmias
This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
C. Preventing musculoskeletal disability
This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
D. Decreasing intracranial pressure
This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
Full Explanation
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?
A. Planning
This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
B. Evaluation
This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
C. Data collection
This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
D. Implementation
This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.
Full Explanation
Choice A reason: This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
Choice B reason: This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
Choice C reason: This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
Choice D reason: This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.
A nurse is teaching a client about the benefits of an electronic health record. Which of the following information should the nurse include in the teaching?
A. Allows client access to their medical record electronically at any time
Choice A: This is the correct answer. An electronic health record (EHR) is a digital version of a client's medical history and other health information that can be accessed by authorized providers and the client. A personal health record (PHR) is a subset of an EHR that allows the client to view and manage their own health information, such as medications, allergies, test results, and appointments. A PHR can enhance the client's satisfaction, engagement, and empowerment in their health care.
B. Provides providers client information to track for research studies
Choice B: This is incorrect. Provides providers client information to track for research studies is not a benefit of an electronic health record, but a potential use of it. EHRs can facilitate health research by providing large and diverse data sets that can be analyzed for various purposes, such as clinical trials, epidemiology, and quality improvement. However, this use of EHRs must comply with ethical and legal standards, such as informed consent, privacy, and confidentiality.
C. Grants significant other access to client information
Choice C: This is incorrect. Grants significant other access to client information is not a benefit of an electronic health record, but a matter of the client's preference and consent. EHRs must protect the client's privacy and confidentiality rights, and only disclose their information to authorized parties, such as health care providers, insurers, or public health agencies. The client can choose to share their information with their significant other or anyone else, but they must give explicit permission to do so.
D. Coordinates all healthcare client has received into one platform
Choice D: This is incorrect. Coordinates all healthcare client has received into one platform is not a benefit of an electronic health record, but a goal of it. EHRs aim to improve the coordination and continuity of care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools. However, this goal is not fully achieved yet, as there are still challenges and barriers to the interoperability and integration of EHRs across different settings and systems.
Full Explanation
Choice A: This is the correct answer. An electronic health record (EHR) is a digital version of a client's medical history and other health information that can be accessed by authorized providers and the client. A personal health record (PHR) is a subset of an EHR that allows the client to view and manage their own health information, such as medications, allergies, test results, and appointments. A PHR can enhance the client's satisfaction, engagement, and empowerment in their health care.
Choice B: This is incorrect. Provides providers client information to track for research studies is not a benefit of an electronic health record, but a potential use of it. EHRs can facilitate health research by providing large and diverse data sets that can be analyzed for various purposes, such as clinical trials, epidemiology, and quality improvement. However, this use of EHRs must comply with ethical and legal standards, such as informed consent, privacy, and confidentiality.
Choice C: This is incorrect. Grants significant other access to client information is not a benefit of an electronic health record, but a matter of the client's preference and consent. EHRs must protect the client's privacy and confidentiality rights, and only disclose their information to authorized parties, such as health care providers, insurers, or public health agencies. The client can choose to share their information with their significant other or anyone else, but they must give explicit permission to do so.
Choice D: This is incorrect. Coordinates all healthcare client has received into one platform is not a benefit of an electronic health record, but a goal of it. EHRs aim to improve the coordination and continuity of care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools. However, this goal is not fully achieved yet, as there are still challenges and barriers to the interoperability and integration of EHRs across different settings and systems.