Medica Surgical Nursing Preparation For Practice 2nd Ed By Osborn – Test Bank

 

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Osborn, Medical-Surgical Nursing, 2e
Chapter 05

Question 1

Type: MCMA

The nurse is providing care for a patient who is unhappy with the health care provider’s care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice. What should the nurse include in the documentation of this event in the patient’s medical record or on the AMA form?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Documentation that the patient was informed that he or she cannot come back to the hospital
2. Documentation that the patient was informed that he or she was leaving against medical advice
3. Documentation that the risks of leaving against medical advice were explained to the patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed

Correct Answer: 2,3,4

Rationale 1: It should be clearly documented that the patient was advised and understands that he or she can come back.

Rationale 2: It should be clearly documented in the patient’s record and on the AMA form that the patient was advised that he or she was leaving against medical advice.

Rationale 3: It should be clearly documented that the patient understands the risks of leaving against medical advice.

Rationale 4: The AMA form includes the name of the person accompanying the patient and any discharge instructions given.

Rationale 5: Facility policy may require that an incident report be completed, but it must not be referenced in the chart. The patient’s record is a legal document, so the nurse should never document that he or she filed an incident report.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-6

 

Question 2

Type: MCMA

A nurse documents this statement in a patient’s medical record: “2/25/–, 2235. At 2015 patient awoke suddenly and complained of shortness of air. Pulse oximetry reading was 82% on room air and audible wheezes could be heard.” This documentation meets which documentation guidelines?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Documentation is timely
2. Documentation is concise
3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and accurate

Correct Answer: 2,3,4,5

Rationale 1: The nurse should document as soon as possible after an observation is made or care is provided. The entry was made in the patient’s medical record at least 2 hours after the patient complaint and should be labeled late entry.

Rationale 2: This entry describes the situation fully but is concise.

Rationale 3: The nurse describes factual events that can be seen, heard, smelled, or touched. It is important to be objective and avoid vague statements that are subjective.

Rationale 4: Both the date and the time of the entry are documented.

Rationale 5: The nurse should document only facts: what he or she can see, hear, and do.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-6

 

Question 3

Type: MCSA

A nurse documents the following in a patient’s medical record: “2/1/__, 1500. Patient appears weak and faint. Patient’s skin is moist and cool, vomited bright red blood with clots. Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0. Pain medication will be given.” This documentation meets which documentation principle?

1. Document objectively.
2. Do not document procedures in advance.
3. Use approved abbreviations.
4. Document changes in patient condition.

Correct Answer: 4

Rationale 1: Documentation should be objective and avoid vague statements that are subjective. Only factual occurrences that can be seen, heard, smelled, or touched should be described. The use of the word “appears” is subjective and could be manipulated later should the treatment or judgment be challenged.

Rationale 2: The nurse has documented that pain medication will be given. This is documenting in advance.

Rationale 3: The Joint Commission has designated the inappropriateness of “u” as an abbreviation. “U” should be written out as “unit(s).” If unsure whether the abbreviation is correct, the nurse should spell out the word; “<” can be misinterpreted, so it should be spelled out as “less than.”

Rationale 4: In general, employers as well as state, federal, and professional standards require documentation to include initial and ongoing assessments, any change in the patient’s condition, therapies given and patient response, patient teaching, and relevant statements by the patient.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-6

 

Question 4

Type: MCSA

A nursing unit has changed its documentation system to documenting by exception. How will this system save time?

1. It eliminates lengthy or repetitive documentation.
2. It allows flexibility and description in the documentation.
3. It allows the reader to easily locate information about a specific problem.
4. It allows for quick and easy retrieval of information.

Correct Answer: 1

Rationale 1: Documenting by exception eliminates lengthy or repetitive documentation.

Rationale 2: Flexible and descriptive documentation is an advantage of the narrative system.

Rationale 3: PIE charting allows easy location of information about a specific problem.

Rationale 4: The electronic health record allows for quick and easy retrieval of information.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-6

 

Question 5

Type: MCSA

A hospital is considering changing its documentation system to reduce the number of medication errors. Which system should the hospital investigate?

1. Problem, intervention, evaluation (PIE) system
2. Electronic medical record
3. Problem-oriented medical record
4. Narrative system

Correct Answer: 2

Rationale 1: The PIE system consists of a list of the patient’s problems, interventions taken to alleviate the problems, and evaluation of the patient’s response to the interventions. This system does not have the specific benefit of reducing medication errors.

Rationale 2: The electronic medical record decreases errors and allows for the reconciliation of the patient’s medications on admission, daily, and on discharge.

Rationale 3: The five components of the problem-oriented medical record are baseline data, a problem list, a plan of care for each problem, multidisciplinary progress notes, and a discharge summary. This system does not have the specific benefit of reducing medication errors.

Rationale 4: Narrative documentation does not have the specific benefit of reducing medication errors.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-6

 

Question 6

Type: MCMA

Which nursing activities are examples of independent functions of the nursing role?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Teaching a soon-to-be-discharged patient about the medication regimen that the health care provider has prescribed
2. Talking with the patient about his or her abilities to manage personal hygiene activities while in the usual state of health at home
3. Incorporating adaptive techniques into nursing care as recommended by occupational therapy
4. Administering analgesic medication ordered by the health care provider
5. Introducing oneself to, and interviewing, the patient to collect data about physical health status

Correct Answer: 2,5

Rationale 1: Teaching the patient about medications prescribed by the health care provider is an interdependent activity.

Rationale 2: This activity is part of the assessment process, which is an independent activity that nurses may perform, based on their education and skills.

Rationale 3: Working in coordination with another health team member is an interdependent activity.

Rationale 4: Administering medication prescribed by the health care provider is an example of a dependent activity.

Rationale 5: These activities are included in assessment, which is an independent activity that nurses may perform, based on their education and skills.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1

 

Question 7

Type: MCSA

The nurse is caring for a 70-year-old patient who was just admitted to an inpatient rehabilitation center. The patient had required total parenteral nutrition for several days, but recently resumed and is tolerating a regular diet. She has another 4 days left in a course of intravenous antibiotics to complete treatment of a positive central line culture. Which nursing action, required in the care of this patient, is considered a dependent role function?

1. Requesting that the health care provider order a consult because the patient states that her dentures no longer fit properly and she has trouble chewing
2. Asking the nursing assistant to demonstrate to the patient how to operate the call system
3. Interviewing the patient to assess whether she needs assistance with getting out of bed
4. Administering the antibiotics prescribed by the health care provider

Correct Answer: 4

Rationale 1: Assessing that the patient has a need that requires further assessment by other team members and communicating that need to the appropriate team member is an example of an interdependent activity.

Rationale 2: This is an independent activity that nurses may perform or delegate, based on their and the delegate’s education and skills.

Rationale 3: Assessment is an independent activity that nurses may perform, based on their education and skills.

Rationale 4: Dependent activities are those prescribed by the health care provider and carried out by the nurse.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1

 

Question 8

Type: MCSA

When asking a patient if a pain medication provided a few hours ago has been effective, the nurse is performing which step of the nursing process?

1. Planning
2. Implementation
3. Evaluation
4. Assessment

Correct Answer: 3

Rationale 1: Planning consists of prioritizing among the chosen nursing diagnoses and determining interventions to move the patient to optimal health.

Rationale 2: Implementation is the actual “doing” step of the nursing process. In this case, implementation occurred when the medication was administered.

Rationale 3: Evaluation focuses on a patient’s behavioral changes and compares them with the criteria stated in the objectives. It consists of both the patient’s status and the effectiveness of the nursing care. Both must be evaluated continuously, with the care plan modified as needed.

Rationale 4: Assessment comprises examining the patient and identifying cues, collecting and analyzing data, and reaching conclusions. In this situation, assessment occurred when the nurse identified that the patient was in pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5-2

 

Question 9

Type: MCSA

The nursing instructor knows that further education is needed when a student makes which statement?

1. “Assessment precedes nursing diagnosis and outcome identification.”
2. “Planning follows nursing diagnosis and outcome identification and precedes implementation.”
3. “Evaluation follows implementation and precedes planning.”
4. “Planning follows assessment and precedes evaluation.”

Correct Answer: 3

Rationale 1: The correct order is assessment, diagnosis, planning, implementation, and evaluation.

Rationale 2: The correct order is assessment, diagnosis, planning, implementation, and evaluation.

Rationale 3: The correct order is assessment, diagnosis, planning, implementation, and evaluation.

Rationale 4: The correct order is assessment, diagnosis, planning, implementation, and evaluation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5-2

 

Question 10

Type: MCSA

A 16-year-old patient has been admitted for treatment of presumptive pelvic inflammatory disease. The patient’s hygiene is poor and she reports living “on the street” for a year. She is febrile and tachycardic and reports pain as 10 on the 1-to-10 scale. The nurse identifies Acute Pain as the priority nursing diagnosis. Which outcome statement is appropriate?

1. The patient’s comfort will be achieved and maintained.
2. The patient will be discharged to a safe living environment.
3. The patient will be reunited with her parents.
4. The patient’s infection will be eradicated.

Correct Answer: 1

Rationale 1: Achieving and maintaining comfort addresses the nursing diagnosis of acute pain related to possible pelvic inflammatory disease identified by the nurse.

Rationale 2: The patient’s living environment is of concern but is not the correct outcome for the priority nursing diagnosis.

Rationale 3: Reuniting the patient with her parents may not be a desired goal for this patient. It also does not match the nursing diagnosis chosen.

Rationale 4: Eradication of the infection is a desired outcome but does not match the chosen nursing diagnosis.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-2

 

Question 11

Type: MCSA

While assessing a female patient from the Middle East, the nurse observes that the patient makes no eye contact and answers questions by nodding or with only a few words. The nurse’s entry in the patient’s record states that the patient “appears to be frightened.” This is an example of which factor associated with assessment?

1. Personal interpretation
2. Subjective data
3. Nursing diagnosis
4. Objective data

Correct Answer: 1

Rationale 1: This is the nurse’s personal interpretation of the patient’s behavior. It has not been validated with the patient. These behaviors may indicate a number of possibilities such as physical, mental, and emotional status or cultural and social norms.

Rationale 2: A direct quote from the patient would be subjective data.

Rationale 3: This statement does not meet the criteria for a nursing diagnosis.

Rationale 4: A description of the patient’s behavior such as “makes no eye contact” would be objective data.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2

 

Question 12

Type: MCSA

The patient tells the nurse that everything “tastes funny” since starting a new medication, making eating unpleasant. The nurse has given this medication to other patients and has not heard this complaint from any of them. The nurse checks the drug reference again to learn whether this is a known side effect of the medication and reads that it is. This information may be helpful in making a nursing diagnosis and determining how best to address this problem. Which data from this scenario is considered subjective?

1. The nurse rechecks the drug reference about known side effects of the medication.
2. The patient tells the nurse that everything “tastes funny.”
3. The nurse reads that this medication can cause a metallic taste in some patients.
4. Other patients who have taken this medication have never reported this side effect to the nurse.

Correct Answer: 2

Rationale 1: Rechecking the drug reference is an example of obtaining factual information about the medication, not data about the patient.

Rationale 2: The statement by the patient is subjective data because it reflects something that only the patient, not the nurse, can perceive.

Rationale 3: That this medication can cause a metallic taste is factual information about the medication, not data about the patient.

Rationale 4: The nurse’s prior experience with this medication is not data about the patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-6

 

Question 13

Type: MCSA

Which statement represents a nursing diagnosis?

1. High risk for delayed maternal-infant bonding due to maternal-infant separation
2. Crohn’s disease
3. Hypertension
4. Appendicitis

Correct Answer: 1

Rationale 1: This is an example of a nursing diagnosis. The statement indicates a clinical judgment that this new mother-baby couplet is at greater risk of experiencing a delay in bonding than other mother-baby couplets.

Rationale 2: Crohn’s disease is a medical diagnosis.

Rationale 3: Hypertension is a collaborative problem.

Rationale 4: Appendicitis is a medical diagnosis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5-3

 

Question 14

Type: MCMA

Which statements reflect collaborative problems?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Knowledge deficit related to infant safety as evidenced by mother leaving crib rail down
2. Sleep apnea
3. Neonatal abstinence syndrome
4. Gestational diabetes
5. Sleep pattern disturbance related to hospital environment and routines

Correct Answer: 2,3,4

Rationale 1: The nurse can diagnose this knowledge deficit and use independent nursing interventions to address the problem. This is a nursing diagnosis.

Rationale 2: Sleep apnea is a medical diagnosis and therefore a collaborative problem.

Rationale 3: Neonatal abstinence syndrome is a medical diagnosis and therefore a collaborative problem.

Rationale 4: Gestational diabetes is a medical diagnosis and therefore a collaborative problem.

Rationale 5: The nurse can diagnose that a patient has disturbed sleep and can intervene to reduce noise and other disturbances in the environment. This is a nursing diagnosis.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5-3

 

Question 15

Type: MCSA

The nurse is using critical thinking to better understand a patient. The nurse is working in which part of the nursing process?

1. Implementation
2. Nursing diagnosis and outcome identification
3. Assessment
4. Planning

Correct Answer: 3

Rationale 1: Using critical thinking to reduce the risk of undesirable results is part of implementation.

Rationale 2: Using critical thinking to identify actual and potential problems is associated with the diagnostic step of the nursing process.

Rationale 3: The goal of assessment is to learn as much as possible about the patient within the context of the nurse-patient relationship. One characteristic of the nurse-patient relationship is the nurse’s continuous focus on better understanding of the patient.

Rationale 4: Using critical thinking to make decisions about an action is associated with planning.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4

 

Question 16

Type: MCSA

Which aspect of critical thinking would the nurse use when making a nursing diagnosis?

1. Making decisions about an action
2. Identifying potential and actual problems
3. Increasing the likelihood of obtaining good results
4. Getting a better understanding of someone else

Correct Answer: 2

Rationale 1: Making decisions about an action is associated with planning.

Rationale 2: Identifying potential and actual problems is analogous to identifying nursing diagnoses, potential and actual.

Rationale 3: Increasing the likelihood of obtaining good results is related to evaluation.

Rationale 4: Getting a better understanding of someone else is related to assessment.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5-4

 

Question 17

Type: MCSA

Critical thinking empowers the nurse to recognize important situational cues and respond quickly to adapt interventions, optimizing their effectiveness and the likelihood of a good outcome. What is true about this aspect of critical thinking?

1. This method of thinking is similar to the way that a skilled nurse uses continued assessment and evaluation to adapt the patient’s care plan.
2. Using this method of critical thinking produces only one correct solution to a problem.
3. The need to change the plan of care indicates that critical thinking and the nursing process are not compatible.
4. The statement proves that critical thinking is another term for the nursing process.

Correct Answer: 1

Rationale 1: The nurse uses critical thinking to continually assess the patient and evaluate response to interventions, then making changes to the plan of care to improve outcomes.

Rationale 2: Critical thinking does not imply that there is only one correct answer to a problem; rather it demands that the nurse looks at information related to the question from many different viewpoints to identify the next step.

Rationale 3: Thinking critically about patient response to interventions encourages the nurse to change portions of the care plan that are not effective.

Rationale 4: Critical thinking and the nursing process are not synonymous; critical thinking enhances and complements the nursing process but is not identical to it.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 05-04

 

Question 18

Type: MCMA

The nurse is using the Kardex to plan a patient’s care. What information would the nurse expect to find in this document?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Nursing notes from the previous shift
2. Schedule of diagnostic tests
3. Level of activity
4. Diet
5. IV therapy

Correct Answer: 2,3,4,5

Rationale 1: Nursing notes are not found on the Kardex.

Rationale 2: The patient’s schedule for diagnostic testing is recorded on the Kardex.

Rationale 3: The patient’s level of activity is recorded on the Kardex.

Rationale 4: The diet prescribed for the patient is recorded on the Kardex.

Rationale 5: The fluid, additives, and rate of IV therapy are recorded on the Kardex.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-7

 

Question 19

Type: MCMA

According to the Health Insurance Portability and Accountability Act (HIPAA), which persons have legal access to the patient’s health record?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient
2. Any nurses working on the unit where the patient is hospitalized
3. Any physician who has credentials to admit patients to the hospital
4. The respiratory therapist who is providing inhalation therapy for the patient
5. The nuclear medicine technician who provided care during the patient’s last hospitalization

Correct Answer: 1,4

Rationale 1: The information in the record belongs to the patient, who has the legal right to review it at any time.

Rationale 2: The only nurses who have the legal right to review the record are the nurses involved with the patient’s care.

Rationale 3: The only physicians who have the legal right to review the record are the physicians involved in the patient’s care.

Rationale 4: The respiratory therapist who is involved in the patient’s care has the legal right to review the patient’s chart.

Rationale 5: If the technician is not involved in caring for the patient on this admission, he or she has no legal right to review the chart.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-5

 

Question 20

Type: MCMA

A nurse manager is discussing documentation standards that reflect Joint Commission safety goals. Which information should the manager share with staff nurses?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. “The documentation of assessment of infants and children should reflect standardization of assessment techniques.”
2. “Documentation should reveal that patients are reassessed according to hospital policy.”
3. “Education about pain and pain management should be documented on all appropriate patients.”
4. “Assessment documentation should make it clear that the assessment was conducted by a registered nurse.”
5. “Traditional care plans should be documented for each patient.”

Correct Answer: 2,3,4

Rationale 1: The assessment process for infants, children, and adolescents should be individualized.

Rationale 2: Each patient should be reassessed at points designated by hospital policy.

Rationale 3: The standard is that patients are educated about pain and pain management.

Rationale 4: The standard states that assessments must be performed by registered nurses.

Rationale 5: Traditional care plans are not required, but an individualized plan of care must be documented.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-5