Importance of documentationPurpose of documentation

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Question Answered step-by-step Importance of documentationPurpose of documentationWho has access to the medical chart? Can the patient take the medical chart home?What gets documented in the following reports? Of these, which stay out of the medical record?               Grievance report               Progress notes               Emergency record               Incident reportMilitary timeAccurate and objective chartingGuidelines for DocumentationDARPersonal space etiquetteTherapeutic Communication TechniquesBarriers to CommunicationCommunication behaviors for nurse-patient relationshipSpecial communication needs – how will you serve these patients?               Deaf               Speech impairment               Mechanical ventilation               UnresponsiveNursing Process – define and think of examples               Assessment               Diagnosis               Planning               Implementation               EvaluationSubjective data – list examples, why is it important?Objective data – list examples, why is it important?When is the use of patient is quotes a valuable part of documentation?Assessment               Inspection – define and list examples               Palpation – define and list examples               Auscultation – define and list examples               Percussion – define and list examplesInterventions               Independent               Dependent               Collaborative Health Science Science Nursing NURSING 1205 Share QuestionEmailCopy link Comments (0)

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QuestionAnswered step-by-step1.  A nurse is suctioning a client through a tracheostomy tube. The nurse plans to apply suction during the withdrawal of the catheter for a period of time no greater than:A)  10 secondsB)  25 secondsC)  30 secondsD)  35 seconds 2. A client who has fallen from a roof and fractured his ribs has arterial blood gas results of: pH 7.48, PaCO2 32 mm Hg, PaO2 89 mm Hg, and HCO3 22 mEq/L.The nurse interprets that the client's blood gases indicate which of the following?A)  Normal resultsB)  Metabolic alkalosisC)  Metabolic acidosisD)  Respiratory alkalosis 3. A client with tuberculosis is being started on antitubercular therapy with isoniazid (INH). The nurse reviews the client's health care record to be sure that which of the following baseline studies have been completed before giving the client the first dose?  A)  Coagulation times  B)  Electrolytes  C)  Serum creatinine  D)  Liver enzymes 4. Which assessment observations would indicate that a client has a possible pneumothorax? Select all that applyA)  Severe dyspneaB)  Asymmetrical chestC)  Dull, radiating chest painD)  Drop in blood pressureE)  Mediastinal shift towards affected side 5. Which of the following statements made by a client with sinusitis would indicate to the nurse that further teaching is required? "I use a warm mist humidifier at night.""I take my decongestants when the doctor ordered.""I will call the physician if my fever comes back.""I will put the ice packs on my nose three times each day." 6. A newly admitted client has asthma and uses inhalers. He takes metaproterenol (Alupent), albuterol (Proventil), and beclomethasone (Vnceril). He complains that he does not like the side effects that these inhaled medications cause. The nurse instructs him that he: A)  Must sit down when using inhalers.B)  Is overdosing himself if he uses all three inhalers within 1 hour.C)  Needs to use the metaproterenol and albuterol inhalers before the beclomethasone.D)  Needs to stop using the inhalers until his next scheduled clinic appointment. 7. A nurse is caring for a client with bronchiectasis. Which of the following nursing care measures should be employed when caring for the client? Select all that apply.A)  Discourage the client from breathing deeplyB)  Perform a postural drainage procedureC)  Provide special mouth care to the clientD)  Monitor the client for the occurrence of hemoptysisE)  Take measures to reduce the humidity of the air 8. A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in this client? A)  HypocapniaB)  Dyspnea on exertionC)  Increased oxygen saturation with exerciseD)  A shortened expiratory phase of respiration 9. A cardiac monitor alarm sounds and a nurse notes a straight line on the monitor screen. The immediate nursing action is to:   A)  Call a code  B)  Check the cardiac leads and wires  C)  Confirm the rhythm  D)  Assess the client  10. A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. The nurse would first:   A)  Call a code  B)  Contact the physician  C)  Administer a bronchodilator  D)  Disconnect the suction source from the catheter  11. A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply.    A)  The drainage system is maintained below the client's chest  B)  An occlusive dressing is in place over the chest-tube insertion site  C)  Vigorous bubbling in the suction-control chamber  D)  50 mL drainage in the drainage-collection chamber  E)  Excessive bubbling in the water-seal chamber  12. The low-exhaled volume (low-pressure) alarm sounds on a ventilator. A nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. The immediate nursing action is to:   A)  Call a code  B)  Call the physician  C)  Ventilate the client manually with a resuscitation  D)  Call the respiratory therapist  13. An emergency room nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign, if noted in the client, would indicate the presence of a pneumothorax?   A)  Bradypnea  B)  Shortness of breath  C)  A low respiratory rate  D)  The presence of a barrel chest  14. A nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. The nurse would:   A)  Continue suctioning  B)  Terminate the suctioning procedure  C)  Obtain a smaller suction catheter  D)  Call respiratory therapy  15. A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which of the following interventions should the nurse perform for this procedure? Select all that apply.   A)  Set the wall suction unit pressure at 160 mm Hg  B)  Apply suction while gently inserting the catheter  C)  Hyperoxygenate the client before suctioning  D)  Apply intermittent suction while rotating and withdrawing the catheter  E)  Apply suction for up to 10 to 15 seconds  16. A client in the clinic has been diagnosed with asthma. Laboratory studies have been done and returned. The nurse knows that the primary antibody affected in asthmatic clients is:   A)  International normalized ratio (INR).  B)  Immunoglobulin E (IgE).  C)  Hepatitis C virus (HCV) antibody.  D)  Carcinoembryonic antigen (CEA).  17. With which of the following data should the nurse be most concerned during assessment of a client with pneumonia?   A)  Capilary refill of more than 3 seconds and buccal cyanosis  B)  An Hct of 47% and white blood cells of 5500/mL  C)  Nonproductive cough and clear lung sounds  D)  Potassium level of 3.7 mEq/L and clear, amber urine  18. The client's left thoracotomy tube is connected to water-sealed drainage and suction. The client is to be transported to the x-ray department. How will the nurse transport the client?   A)  Disconnect the suction; maintain the water-seal drainage.  B)  Disconnect the chest tube from the water-seal draiange.  C)  Ask if the x-ray department can possibly do its procedure in the client's room.  D)  Obtain a portable suction machine form central supply to transport the client.  19. A nurse is caring for a client with tuberculosis (TB). Which of the following information should the nurse provide to the client? Select all that apply.    A)  Persons with latent TB show a negative skin test reaction  B)  TB spreads to other parts of the body through the blood  C)  TB spreads by inhalation of infected droplets  D)  Pulmonary TB is characterized by high fever  E)  Diabetic clients have an increased risk for TB infection  20. The nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentations, completed by the nurse indicate the resolution of the infection? Select all that apply.    A)  Palpate vibrations over the chest wall when the client speaks  B)  Bronchovesicular sounds heard over the upper lung fields  C)  Lung fields documented as clear in the bases  D)  Dull sounds percussed over the lung tissue  E)  Decreased fremitus when the client speaks "99"  21. A nurse is caring for a client diagnosed with pneumonia. What intervention should be included in the client's nursing care plan?   A)  Instruct the client to take shallow and timely breaths.  B)  Restrict the client's fluid intake to juices with vitamin C.  C)  Encourage the client to lie in the supine position a few hours a day.  D)  Maintain orthopneic position when possible.  22. A client who has been taking isoniazid (INH) for 1-1/2 months complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing:   A)  Hypercalcemia  B)  Peripheral neuritis  C)  Small blood vessel spasm  D)  Impaired peripheral circulation  23. A client has the following laboratory values: a pH of 7.55, an HCO3 level of 22 mm Hg, and a PCO2 of 30 mm Hg. What should the nurse do?   A)  Perform Allen's test.  B)  Prepare the client for dialysis.  C)  Administer insulin as ordered.  D)  Encourage the client to slow down breathing.  24. A nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the lef of the chair and accidentally dislodges from the insertion site. The immediate nursing action is to:   A)  Transfer the client back to bed.  B)  Cover the insertion site with sterile gauze.  C)  Contact the physician.  D)  Reinsert the chest tube.  25. A client is scheduled for a thoracentesis. The nurse's primary responsibility during this procedure is:   A)  Handing the physician collection bottles.  B)  Keeping the client still and in proper position.  C)  Arranging for follow up x-rays.  D)  Setting up the three-bottle drainage system.  26. A nurse is caring for a client after laryngectomy. Which of the following postoperative nursing care measures should be employed when caring for the client? Select all that apply.    A)  Reestablish oral feeding of the client  B)  Remove secretions through the tracheostomy tube  C)  Teach the client how to use the tracheoesophageal puncture for speech  D)  Instruct the client to wear a thin, filmy scarf over the opening  E)  Administer oxygen using a mask or T-piece  27. A client with asthma tells the nurse that he does not use his albuterol (Ventolin) inhaler because it is the same thing as his ipatropium (Atrovent). The nurse needs to teach him that both inhalers contain:   A)  Medications that cause bronchodilation but in different ways; he should wait 5 minutes after using the one inhaler before using the next.  B)  Medications that cause bronchoconstriction but in different ways; he shoould wait 15 minutes after using one inhaler before using the next.  C)  Medications that are used for bronchospasm; he can use either one if he feels an attack is coming on.  D)  The same medication; the names are different because they are made by a different company. He is acting correctly.  28. A nurse caring for a client after lung surgery will help remove secretions using suction. What should the nurse do when performing the procedure?   A)  Place the client in a supine position for the procedure.  B)  Avoid pulling the catheter back when inserting.  C)  Avoid rotating the catheter when withdrawing.  D)  Flush the catheter with sterile saline between insertions of the catheter.  29. The nurse is educating older adults in a senior citizens center about the signs and symptoms of emphysema. Which is the first symptom of this respiratory alteration?   A)  Leaning forward instead of lying down  B)  Barrel chest  C)  Contracting the neck muscles when breathing  D)  Difficulty breathing following exertion  30. A nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse would first:   A)  Contact the registered nurse.  B)  Check the client's blood pressure and heart rate.  C)  Check for kinks in the chest drainage system.  D)  Connect a new drainage system to the client's chest tube.  31. The nurse is caring for a client who is experiencing a panic attack. The nurse instructs the client to breathe into a paper bag. What respiratory alteration is this client most likely experiencing?   A)  Hyperventilation  B)  Aspiration  C)  Hypoxia  D)  Hypoxemic hypoxia  32. A nurse has given the client with tuberculosis instructions for proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes which of the following?   A)  Discard used tissues in a plastic bag.  B)  Wash hands at least four times a day.  C)  Brush teeth and rinse the mouth once a day.  D)  Turn the head to the side if coughing or sneezing.  33. A nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. The nurse would first:   A)  Continue suctioning to remove the blood.  B)  Check the amount of suction pressure being applied.  C)  Remove the suction catheter from the nose and begin vigorous suctioning through the mouth.  D)  Encourage the client to cough out the bloody secretions.  34. The nurse is caring for a client diagnosed with pneumonia. The nurse observes that the client is experiencing breathing difficulty. What position will help to alleviate the client's dyspnea?   A)  Lying supine with a single pillow  B)  Sitting upright or in a semisitting position  C)  Lying with the legs slightly elevated  D)  Lying supine with head slightly lowered  35. Which nursing measures should be initiated for clients experiencing chronic obstructive pulmonary disease (COPD) to improve ventilation and to overcome hypoxic states? Select all that apply.   A)  Use of bronchodilators, expectorants, and liquefying agents  B)  Decreased fluid intake (500 to 1,000 mL/day)  C)  Consistent use of oxygen  D)  Limited activity  E)  Use of Fowler position  36. A nurse is caring for a client with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. The immediate nursing action is to:   A)  Clamp the chest tube  B)  Reattach the chest tube to the drainage system.  C)  Call the physician.  D)  Instruct the client to inhale.  37. A client arrives to the emergency department with an episode of status asmaticus. The nurse first:   A)  Places the client in high-Fowler's position  B)  Obtains a set of vital signs  C)  Obtains equipment for starting an intravenous line  D)  Administers oxygen at 21%  38. A client attached to mechanical ventilation suddenly becomes restless and pulls out the endotracheal tube. The nurse would first:   A)  Check the client for spontaneous breathing.  B)  Prepare for reintubation.  C)  Call the physician.  D)  Call a code.  39. A nurse is admitting a client to the nursing unit who is suspected of having tuberculosis. The nurse plans to admit the client to a room that has:   A)  Ultraviolet light and three air exchanges per hour  B)  Ten air exchanges per hour and venting to the outside  C)  Venting to the outside and ultraviolet light  D)  Venting to the outside, six air exchanges per hour, and ultraviolet light  40. During a care conference, the head nurse asks if the nursing diagnosis of ineffective airway clearance related to bronchial secretions is still appropriate for the client. The nurse caring for this client can best evaluate this by:   A)  Taking the client's temperature.  B)  Checking the rate and strength of the client's pulse.  C)  Counting the client's respirations for 1 full minute.  D)  Ascertaining the effectiveness of the client's cough.  41. The nurse is suctioning a postoperative client to remove excess secretions. Which complications are associated with this procedure? Select all that apply.   A)  Syncope  B)  Dysrhythmia  C)  Hyperventilation  D)  Vasodilation  E)  Desaturation  42. A nurseis is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations is made?   A)  Skin color becomes cyanotic  B)  Secretions are becoming bloody  C)  Coughing occurs with suctioning  D)  Heart rate decreases from 78 to 54 beats/ minute  43. The nurse is told that the blood gas results indicate a pH of 7.55 and a PCO2 of 30 mm Hg. The nurse determines that these results indicate:   A)  Metabolic acidosis  B)  Metabolic alkalosis  C)  Respiratory acidosis  D)  Respiratory alkalosis  44. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when:   A)  Suctioning is required frequently  B)  Excessive secretions are suctioned from a tracheostomy  C)  The client;s skin and mucous membranes are light pink  D)  Aspiration of gastric contents occur  45. A nurse has given the client taking ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if he immediately reports:   A)  Impaired sense of hearing  B)  Distressing gastrointestinal side effects  C)  Orange-red discoloration of body secretions  D)  Difficulty discriminating the color red from green  46. A nurse is caring for a client after lung surgery. What device and technique should the nurse teach the client to use to prevent atelectasis?   A)  Incentive spirometer; inhale deeply  B)  Straw; blow slowly  C)  Peak flow meter; blow out forcefully  D)  Wound-suction device; inflate every 4 hours  47. A client has a chest tube that is attached to a Pleur-Evac drainage system. The client asks the nurse, "Can the tube come out faster if you turn the wall suction up higher?" The nurse's response is based on the understanding that turning up the wall suction would:   A)  Not increase the actual suction in the system, but would cause more air to be pulled through the air vent and suction chamber to the suction source  B)  Not increase the actual suction in the system, but could cause the client to suffer injury  C)  Increase the actual suction in the system, but could damage lung tissue  D)  Increase the actual suction in the system and is a good idea  48. A client is diagnosed with bronchial asthma. What intervention should the nurse include in the client's education?   A)  Take precautions to prevent the transmission of the disease.  B)  Avoid sleeping in a supine position to avoid recurrent asthma attacks.  C)  Rinse and clean the mouthpiece of the inhaler daily.  D)  Instruct the client to avoid deep breathing exercises.  49. A client is to begin medications for tuberculosis (TB). Which of the following statements made by the client would require further teaching?   A)  "I should cover my mouth and nose when sneezing."  B)  "I won't ever be able to get a PPD again."  C)  "I am glad I will only take these drugs for a few months."  D)  "I can resume normal activity as long as I plan for rest periods."  50. A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in evaluating this client?   A)  Hypocapnia  B)  A hyperinflated chest on x-ray  C)  Increased oxygen saturation with exercise  D)  A widened diaphragm noted on chest x-ray           Health ScienceScienceNursingShare Question
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