Which of the following demonstrates appropriate nursing documentation?
•Documentation should be objective and only include findings that are smelled, seen, felt, or heard.
•Pressure ulcer documentation should include the size, location, stage, exudates and other objective descriptors.
•Drawing conclusions about a patient's feelings or thoughts is not appropriate documentation.
•Documenting that the patient had a terrible night is not precise enough.
A nurse working in a bariatric clinic is preparing educational materials for a presentation to a group of clients who will be undergoing gastric bypass surgery. According to Healthy People 2020, the nurse should include which of the following guidelines to assist this patient population?
A nurse is documenting the intake and output of her patients. The nurse would consider which of the following insensible fluid loss?
To help a mother anticipate the safety needs of her nine-year-old son who is learning to ride a bicycle, the nurse should teach that:
While preparing to administer a subcutaneous injection, the nurse disinfects the injection site and waits for how long before administering the injection?
A nurse noticed a nursing assistant entering the room of a patient with tuberculosis. Which action by the nursing assistant demonstrates a need for education on airborne precautions?
A nurse has been teaching a 16-year-old boy about health promotion. Which of the following statements made by the boy indicates effective education?
Another RN has called in sick, leaving 10 pediatric cancer patients to be cared for by one RN and 3 nursing assistants. What should the nurse do?
A patient who will undergo plastic surgery tells the nurse she is embarrassed about the surgery and asks the nurse not to tell anyone. How should the nurse respond?
After taking shift report from the day nurse, a senior nurse on the unit comes to you and says, "Double check all your orders and MARs before you get started. The nurse you followed is a total screw up." How should you handle this situation?
Three nurses are discussing a patient's manic symptoms in the cafeteria. The patient's daughter overhears details that she was unaware of and begins to tell the rest of the family. The nurses are guilty of which of the following?
The nurse is caring for a patient with an infiltrated IV from normal saline. The nurse first stops the infusion. What other action demonstrates an appropriate response?
A patient's sister is in nursing school and requests to see the patient's medical record. She states that it would be a great learning opportunity. What should the nurse do?
When preparing the morning medications for Mr. Smith, the nurse notices digoxin in his med drawer. He does not have an order for digoxin on his medication administration record. What should the nurse do?
Before administering medications, the nurse should assess the kidney and liver function of which of the following populations?
The nurse is teaching a mother on safety measures when caring for a 19-month-old child. Which of the following statements by the mother indicates that the teaching provided by the nurse regarding safety has been effective?
A nurse on the cardiac telemetry floor is preparing to admit a new patient with complaints of chest pain and shortness of breath. The nurse may delegate to the certified nursing assistant (CNA) which one of the following?
Before administering IV medication into an unused IV catheter, the nurse should flush the IV line with:
A patient with a nasogastric (NG) tube has medications ordered. The nurse recognizes that which of the following medications can be administered through the NG tube:
A physician orders a blood transfusion for an anemic patient. Before transfusing the patient, the nurse should:
Of the following nursing diagnoses, which is most appropriate for the care plan of a patient having trouble remembering to take all of his medications?