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NRSG 91 TEST 2 2025 (ACTUAL TEST) | ALL
QUESTIONS AND CORRECT ANSWERS |
GRADED A+ | VERIFIED ANSWERS | LATEST
EXAM
How can subjective and objective data be organized? ---------CORRECT ANSWER-----------------Using a computerized or written form, modifying it according to patient status What is the purpose of a medical diagnosis? ---------CORRECT ANSWER-- ---------------To determine the identity of a disease or illness What is the purpose of a nursing diagnosis? ---------CORRECT ANSWER--- --------------To determine health problems within the domain of nursing What should be done before identifying specific nursing problems? --------- CORRECT ANSWER-----------------Take a history and do the assessment first What is the basis for selecting nursing goals and interventions? --------- CORRECT ANSWER-----------------Identifying specific nursing problems What is the purpose of a nursing diagnosis statement? ---------CORRECT ANSWER-----------------To provide common nomenclature globally and meet documentation standards
How many types of nursing diagnosis statements are there? --------- CORRECT ANSWER-----------------Four What is an actual nursing diagnosis? ---------CORRECT ANSWER------------ -----A nursing diagnosis that is currently present What is a risk nursing diagnosis? ---------CORRECT ANSWER----------------- A nursing diagnosis that represents a potential problem What is a possible nursing diagnosis? ---------CORRECT ANSWER----------- ------A nursing diagnosis that requires further data collection What is a wellness nursing diagnosis? ---------CORRECT ANSWER---------- -------A nursing diagnosis that focuses on the patient's potential for enhancement of well-being What are the 3 standard statements for documentation according to the CNO Practice Standard? ---------CORRECT ANSWER----------------- Communication, Accountability, Security What are the requirements for communication in documentation according to the CNO Practice Standard? ---------CORRECT ANSWER----------------- Reflects all aspects of the nursing process, legible, full signature or initials and designation
What does DAR stand for in the focus charting format? ---------CORRECT ANSWER-----------------Data, Action, Response What is an example of a SOAP note? ---------CORRECT ANSWER----------- ------S- Pt. states 'I have always been overweight...' O- weight = 95 kg; height = 167 cm; BP = 120/70; NKDA; total cholesterol level = 190 mg/dL A- Overweight as BMI = 34.06. Hypercholesterolemia. P- Short term goal: Pt. to consult with Dietician. What is charting by exception (CBE)? ---------CORRECT ANSWER----------- ------Records only abnormal or significant data. What is case management documentation? ---------CORRECT ANSWER--- --------------Documentation related to the management of a patient's case. What are flow sheets and checklists? ---------CORRECT ANSWER------------ -----Forms used to document specific information or tasks. What is a kardex? ---------CORRECT ANSWER-----------------A flip file containing a patient's basic information for quick reference. What are critical pathways or care maps? ---------CORRECT ANSWER------ -----------Preprinted forms with specific goals, interventions, and time frames for patient care.
What are standardized nursing care plans? ---------CORRECT ANSWER---- -------------Preprinted care plans that can be modified based on individual needs. What is a handoff report? ---------CORRECT ANSWER-----------------The process of passing patient-specific information from one caregiver to another. What are the different types of handoff reports? ---------CORRECT ANSWER-----------------Oral, face-to-face, telephone, written, recorded. When do handoff reports typically occur? ---------CORRECT ANSWER------- ----------Between providers, between shifts, at unit transfer or discharge referral. What are the functions of handoff reports? ---------CORRECT ANSWER----- ------------Provide accurate and timely information about care, treatment, and services rendered. What do handoff reports address? ---------CORRECT ANSWER----------------
- Current condition, anticipated changes, and communication problems. What can be the primary cause of more than half of sentinel events? --------
- CORRECT ANSWER-----------------Communication problems.
What is a recommendation? ---------CORRECT ANSWER----------------- Action to correct a problem. What is ISBAR? ---------CORRECT ANSWER-----------------Introduction, Situation, Background, Assessment, Recommendations. What is an incident report? ---------CORRECT ANSWER----------------- Report documenting unusual events involving patients, visitors, or staff. Give examples of incidents that require a report. ---------CORRECT ANSWER-----------------Fall, medication error, equipment malfunction. What should be included in an incident report? ---------CORRECT ANSWER-----------------Factual details, objective and nonjudgmental. What is a health care record? ---------CORRECT ANSWER----------------- Written or electronically generated information about a patient. What information is included in a health care record? ---------CORRECT ANSWER-----------------Patient's history, current health status, care, treatments & services provided, discussions with the patient and/or significant others, date & time and the health care professional's signature and status.
What is the purpose of a health care record? ---------CORRECT ANSWER-- ---------------Facilitation of information flow to support continuity, quality, and safety of care. What is the goal of a health care record? ---------CORRECT ANSWER------- ----------To describe facts clearly and concisely to improve communication. What are the functions of a health care record? ---------CORRECT ANSWER-----------------Communication tool, promotes continuity of care, single data access point for staff, legal document, clinical data archive, tool for research, audits, quality control, education, performance appraisals. What standards must documentation in Ontario comply with? --------- CORRECT ANSWER-----------------CO's Professional and Practice Standards. What are the requirements for a health care record to provide legal evidence of care? ---------CORRECT ANSWER-----------------Permanent record, clear and concise, accurate, complete and objective, timely, accessible, must not be altered or have spelling or grammar errors. What are potential problems with a written health care record? --------- CORRECT ANSWER-----------------May not fax or photocopy well if black ink is not used, spaces can be left, can be difficult to locate, single-user access, fragile and susceptible to damage, handwriting may be illegible. What are potential problems with an electronic health care record? --------- CORRECT ANSWER-----------------Initial cost, sharing of passwords.
What are the requirements for strong passwords in an electronic health record system? ---------CORRECT ANSWER-----------------Frequent changes and a combination of letters, numbers, and/or symbols What are some common parts of a health care record? ---------CORRECT ANSWER-----------------Patient identification and demographic data, informed consent for treatment and procedures, advance directives, medical and progress notes, doctors' orders, nursing database, reports of diagnostic studies, operative record, discharge plan and summary What is the obligation of nurses regarding patient information? --------- CORRECT ANSWER-----------------Nurses have a professional and legal obligation to protect patient information What is the right to privacy in healthcare? ---------CORRECT ANSWER------ -----------The right to be free from intrusion or disturbance in private life What is the importance of written releases in sharing patient information? -- -------CORRECT ANSWER-----------------Written releases are needed to share information from the chart What should be done with worksheets once they are no longer needed? ---- -----CORRECT ANSWER-----------------Worksheets should be shredded Why should nurses be cautious with abbreviations in charting? --------- CORRECT ANSWER-----------------Abbreviations that may be misunderstood can compromise patient safety
What should nurses use to facilitate effective communication in charting? -- -------CORRECT ANSWER-----------------Accepted abbreviations and acronyms What are the guidelines for accuracy in charting? ---------CORRECT ANSWER-----------------Be factual, professional, non-judgmental, avoid general or vague terms, use exact quotes, include date, time, full signature, and correct title/status What are the guidelines for written documentation? ---------CORRECT ANSWER-----------------Use black ink, no erasing or white-out, be legible What should be done when charting only care provided? ---------CORRECT ANSWER-----------------Ensure accuracy in charting What precautions should be taken with electronic documentation? --------- CORRECT ANSWER-----------------Do not share password How should another patient be referred to in documentation? --------- CORRECT ANSWER-----------------As 'patient's room-mate' What should be included on each page of documentation? --------- CORRECT ANSWER-----------------Patient ID (sticker or addressograph)
What are the characteristics of the nursing process? ---------CORRECT ANSWER-----------------Person-focused, goal-oriented, individualized, applies to all ages and health problems. What is the first step of the nursing process? ---------CORRECT ANSWER-- ---------------Assessment - deliberate and systematic collection of data. What are the two stages of assessment? ---------CORRECT ANSWER------- ----------Collection and verification of data, analysis of data. What are the types of data in assessment? ---------CORRECT ANSWER---- -------------Subjective (pt's descriptions) and objective (nursing observations). What are the sources of data in assessment? ---------CORRECT ANSWER- ----------------Primary sources (the pt) and secondary sources (family and significant others). What are some examples of secondary sources? ---------CORRECT ANSWER-----------------Nursing notes, change of shift report, database, lab and diagnostic results, medical records What are some examples of tertiary sources? ---------CORRECT ANSWER- ----------------Nurse's experience, relevant literature
What is an interview in the context of collecting subjective data? --------- CORRECT ANSWER-----------------An organized conversation with a patient What are the three phases of an interview? ---------CORRECT ANSWER---- -------------Orientation phase, working phase, termination phase What are some skills to have during an interview? ---------CORRECT ANSWER-----------------Reasonable eye contact, use plain language, let the patient finish speaking, take notes What is the first step in the nursing process? ---------CORRECT ANSWER-- ---------------Assessment What organization creates the list of nursing diagnosis phrases? --------- CORRECT ANSWER-----------------NANDA International When was NANDA originally started? ---------CORRECT ANSWER----------- ------ 1982 What is an at-risk nursing diagnosis? ---------CORRECT ANSWER------------ -----Identifies potential health problems that a person is vulnerable to. What is a health promotion diagnosis? ---------CORRECT ANSWER---------- -------Focuses on improving the overall well-being and preventing illness.
Can a patient have multiple goals? ---------CORRECT ANSWER--------------- --Yes, a patient can have multiple goals for different problems Can the order of goals change? ---------CORRECT ANSWER----------------- Yes, the order of goals can change in minutes Where do goals of care come from? ---------CORRECT ANSWER------------- ----They come from nursing diagnoses What is an example of a nurse-initiated intervention? ---------CORRECT ANSWER-----------------Turning the patient every 2 hours What is an example of a physician-initiated intervention? ---------CORRECT ANSWER-----------------Requesting a medication reassessment for increased pain What is an example of a collaborative intervention? ---------CORRECT ANSWER-----------------Consulting and collaborating with the inter- professional healthcare team What is the purpose of evaluation in the nursing process? --------- CORRECT ANSWER-----------------To determine if the patient's goals were met
What should be done to evaluate the patient's goals? ---------CORRECT ANSWER-----------------Collect data from the patient and ask for their agreement How should the findings of the evaluation be interpreted? --------- CORRECT ANSWER-----------------Interpret and summarize the findings Is it easier to evaluate the longer you look after a patient? --------- CORRECT ANSWER-----------------Yes, it becomes easier to evaluate with more time spent with the patient What are the options when evaluating the plan of care? ---------CORRECT ANSWER-----------------Terminate, modify, or continue with the plan of care What should be done when a goal is not met? - --------CORRECT ANSWER-----------------Repeat the entire nursing process sequence for that nursing diagnosis to identify necessary changes to the plan What is the importance of incorporating evaluation into practice? --------- CORRECT ANSWER-----------------Minimizes errors and ensures appropriate and relevant care.
