NURS100 / NURS 100 Assessment 3 V1: Fundamentals of Nursing | Latest 2026–2027 Update | Questions with Correct Answers | Grade A – WCU

NURS100 / NURS 100 Assessment 3 V1: Fundamentals of Nursing | Latest 2026–2027 Update | Questions with Correct Answers | Grade A – WCU 2026 / 2027 Academic Year Q: A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? 1. "Avoid rushing when documenting an entry in the medical record." 2. "Use correction fluid to remove the entry." 3. " Draw a single line through the statement and initial it." 4. Enter only objective and factual info about a patient in the medical record 4- Nurses should enter only objective and factual info about patients. Opinions have no place in the medical record. Because the info has already been entered and is no incorrect, it should be left on the record Q: A preceptor observes a new graduate nurse discussing changes in a patient's conditions with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some lab tests from the physician at the end of the conversation. During the conversation the new grad writes the orders on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? 1. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone 2. Documents the date and time of the phone 3- When provider orders for new medications are entered into an electronic medical record, the new orders are available to pharmacists using the same electronic system within the hospital. To improve patient safety, many hospitals have a policy that new medications are not to be administered until a pharmacist reviews the new orders, and verifies that there is no document allergies to the medications, the ordered doses are appropriate, and that there are no potential medication interactions with medications already ordered for a patient. Nurse enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur Q: As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, " I don't know what's going on: I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of he patient? 1. "The patient has a defiant attitude and is demanding test results." 2. "The patient appears to be upset with the nurse because he wants his test results immediately." 3. "The patient is demanding and is complaining about the doctor." 4. "The patient stated feelings of frustration from the lack of info received regarding test results." 4- This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient has a defiant attitude or is demanding is judgmental, and info in the medical record should be factual and nonjudgmental. Noting that the patient appears upset with the nurse needs to be more specific; it does not provide enough info regarding the reason for the patient's concerns Q: The nurse is reviewing the HIPAA regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? 1. HIPAA allows hospital staff access to your medical record 2. HIPAA limits the info that is documented in your medical record 3. HIPAA provides you with greater protection of you personal health info 4. HIPAA enables health care institutions to release all of your personal info to improve continuity of care 3- HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patien'ts medical record Q: A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? 1. "Only your family can read your medical record" 2. "You have the right to read your record" 3. "Patient's are not allowed to read their records" 4. "Only health care workers have access to patient records" 2- Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission Q: Which of the following documentation entries is most accurate? 1. "Patient walked up and down hallway with assistance, tolerated well." 2. "Patient up, out of bed, walked down hallway and back to room, tolerated well." 3. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." 4. "Patient walked 50 feet and back down hallway with assistance from nurse: HR 88 and regular before exercise, HR 94 and regular following exercise" 4-This provides the most accurate, objective info for the chart Q: Label each line of documentation with the appropriate SOAP category. 1. Re-positioned patient on right-side. Encouraged patient to use patient-controlled analgesia (PCA) devise 2. "The pain increases every time I try to turn on my left side." 3. Acute pain related to tissue injury from surgical incision 4. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation 1- Plan 2- Subjective 3-Assessment 4-Objective Q: While working on a unit within a hospital, the nurse was able to access a patient's medical record and review the education that other nurses provided during an initial hospitalization and three subsequent clinic visits that occurred in different provider's offices over the past 6 month. This type of feature is most common in an . Electronic health record Q: The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a RN who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of info does the nurse include in the documentation? (select all) 1. The patient's name, age, and admitting diagnosis 2. The discussion of any allergies to food and medications that the patient has 3. The nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" 4. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650mg of Tylenol 5. Description of any unresolved problems and current interventions in place 1,2,4,5- During transfer to another institution, include essential background info such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Q: The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (select all) 1. Documents a medication given by another nursing student 2. Includes the date and time of the entry into the medical record 3. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room 4. Leaves a slip of paper with her user name and password in the patient's room 5. Stats to enter "Docusate sodium 100mg ordered at 0800 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this does the problem will get worse." As a narrative comment 1,4- Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed. Personal passwords used to access an electronic medical record need to be kept secure to provide for safety and confidentiality of patient info. Q: A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantages of using CPOE? 1. "CPOE reduces transcription errors." 2. "CPOE reduces the time needed for health care providers to write orders." 3. "CPOE eliminates verbal and telephone orders from health care providers." 4. "CPOE reduces the time nurses use to communicate with health care providers." 1- CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly eliminating the need to transcribe orders. There is no evidence that CPOE reduces the time needed for providers to write orders for their patients, or the time nurses must spend communicating with providers. Nurses use CPOE systems under certain circumstances to enter orders given by a provider in person, or over the phone Q: The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2mg intravenously for pain at 3:45pm, changed the dressing over the patient's abdominal incision at 5:34pm, and administered Ancef 1g IV at 8:00pm. Using correct military time, label the documentation for each task with the time that it was completed. 1. Morphine 2mg IV given for pain rating of 8/10 2. Dressing changed over midline abdominal incision using aspetic technique 3. Ancef 1g given IVPB over 30 minutes 1- 1545 2-1734 3-2000 Q: The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 ml per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? 1. Electronic health record 2. Clinical documentation 3. Clinical decision support system 4. Computerized physician order entry 3-A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other info may be provided to the user Q: While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only info documented in that section is "WDL." The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? 1. The nurse caring for the patient forgot to document on the pulmonary system 2. The EMR uses a charting-by-exception format 3. The computer shut down unexpectedly when the nurse was documenting the assessment 4. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment 2- Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits Q: What is the appropriate way for a nurse to dispose of info printed out from a patient's electronic health record? 1. Rip the papers up into small pieces and place the pieces into a standard trash can 2. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit 3. Place papers with patient info in a secure canister marked for shredding 4. Burn documents with patient info in the steel sink located within the dirty supply room on the patient care unit 3- Confidential patient info should be shredded. It is generally collected in large secure containers and shredded at scheduled times Q: A nurse enters the examination room of the emergency clinic and meets a 29-year-old patient who missed her last two follow-up appointments. The nurse notes from the medical record that the patient has high blood pressure that the doctor has been trying to help her manage. The patient just spoke with her doctor who left the room frustrated because the patient has not been taking her medication as prescribed. The patient confronts the nurse, saying, "I'm tired of being treated this way; no one cares. I need to find another doctor!" Using the C-LARA mnemonic, match the nurse's response to the correct letter of the mnemonic. 1. The nurse acknowledges that it is absolutely reasonable for patients to expect that their health care providers their situations and that it is disappointing when they have experiences that make them feel like they do not 2. The nurse uses a relaxation technique before responding to the patient's 1-B, 2-D, 3-A, 4-C, 5-E Q: Which of the following are considered social determinants of health? (select all) 1. Lack of primary health care providers in a zip code 2. Poor-quality public school education that prevents a person from developing adequate reading skills 3. Lack of affordable health insurance 4. Employment opportunities that do not provide paid vacation or sick leave 5. The number of times a person exercises during a week 6. Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of his or her home 1,2,3,4,6, The social determinants of health are the circumstances in which people are born and grow up; the neighborhood in which the live, work,, and age; and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social, policies, and politics Q: Which of the following changes can help create a more inclusive environment for lesbian, gay, bisexual, and transgender patients? (select all) 1. Explicitly including sexual orientation and gender identity into nondiscrimination policies 2. Displaying art that reflects LGBT community 3. Modifying health care forms to provide opportunities for gender identity and sexual orientation disclosure 4. Not asking patients about their gender identity and sexual orientation to avoid making them uncomfortable 5. Ensuring access to unisex or single-stall bathrooms 1,2,3,5, All of these help to create a more inclusive environment for LGBT patients. It is important to ask patients about their gender identity and sexual orientation to avoid making them uncomfortable Which of the following are examples of problems with the health care system that contribute to health disparities? (select all) 1. A health care provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire about the reasons for missed visits 2. The discharge nurse at a hospital uses teach back with patient to ensure that she has communicated the discharge instructions clearly 3. A community hospital lacks an adequate staff of social workers who are able to ensure patient's access to resources they need to take care of their health 4. A hospital discharges a patient without ensuring that the patient has a primary care provider and has made a follow-up appointment 5. A nurse uses a family member as an interpreter to explain the patient's medications 6. The hospital conducts quality improvement without stratifying data by race, ethnicity, lan 1,3,4,5,6- A large body of research shows that health care systems and health care providers contribute significantly to the problem of health disparities. Inadequate resources, poor patient-provider communication, a lack of culturally competent care, system fragmentation, and inadequate language access are critical factors that contribute to inequities in patient outcomes. RESPECT is the mnemonic for Rapport, Empathy, Support, Partnership, Explorations, Cultural competence, Trust Match each letter of the RESPECT mnemonic with a statement that describes the concept the letter represents 1. Ask about and try to understand barriers to care and adherence, and then offer resources to help the patient overcome them, involving family members if appropriate and reassuring the patient that you are and will be available to help 2. Patients may have different reasons for not disclosing important info. Earn a patient's confidence through actions and attitude that demonstrate respect, compassion, and your interest in partnership 3. Work closely together with the patient by being flexible with regard to issues of control, negotiating roles when necessary, and stressing that you will be working together to mutually address medical problems 4. Provide explanations for the process and your action, checking often for understanding and using verbal clarification techniques such as Teach Back 5. Approach each e 1G, 2F, 3A, 5D, 6E, 7B A patient is admitted through the ED after a serious car accident. The nurse assess the patient and quickly learns that he speaks little English. Spanish is his primary language. The nurse speaks some Spanish. Which interventions would be appropriate at this time? (select all) 1. The nurse requests a professional interpreter 2. Since this is an emergent situation, the nurse will interpret and identify the patient's priority needs 3. The nurse determines the interpreters qualifications and makes sure that the interpreter can speak the patient's dialect 4. The nurse uses short sentences to explain the treatment provided in the ED 5. The nurse directs questions to the patient by looks at the patient instead of the interpreter 1,3,4,5- In any situation the nurse should use an interpreter and not the family to convey info to the patient. As the nurse you need to question the interpreter about his or her ability to speak the patient's dialect. It is your responsibility to introduce the interpreter to the patient. You are communicating with the patient and should direct your questions and responses to the patient and not the interpreter. Short sentences make it easier for the patient to understand complex info A new nurse is caring for a hospitalized obese patient who is homeless. This is the first time the patient is scheduled for surgery. Which of the following is a universal skill that will help the nurse work effectively with this patient? 1. The nurse shifts her focus to understanding the patient by asking her, "describe for me the course of your illness." 2. The nurse tells the patient, "Your choices of foods and unwillingness to exercise are adding to your health problems." 3. The nurse asks the patient, "Tell me about the main problems you have had with your health from not having a home." 4. The nurse explains, "Because you have obesity, it is important to know the effects it has on wound healing because of reduced tissue perfusion." 3- This response enables the nurse to elicit the patient's explanation of her health problems and their causes. Choice 1 uses a biomedical explanatory model instead of the patient's explanatory model. Choice 2 shows the nurse's disrespect and unwillingness to understand the patient's perceptions and health beliefs Which statement made by a new graduate nurse about the teach-back technique requires intervention and further instruction by the nurse's preceptors? 1. "After teaching a patient how to use an inhaler, I need to use the Teach Back technique to test my patient's understanding ." 2. "The Teach Back technique is an ongoing process of asking patients for feedback." 3. "Using Teach Back will help me identify explanations and communication strategies that my patients will most commonly understand." 4. "Using pictures, drawings, and models can enhance the effectiveness of the Teach Back technique" 1- Teach back is no a test of patient knowledge or ability to use devices but a confirmation of how well the nurse explained concepts to patients A nurse has worked in a home health agency for a number of years. She goes to visit a patient who has diabetes and who lives in a public housing facility. This is the first time the nurse has cared for the patient. The patient has four other family members who live with her in the one-bedroom apartment. Which of the following, based on Caminha-Bacote's model of cultural competency, is an example of cultural awareness? 1. The nurse begins a discussion with the patient by asking, "Tell me about your family members who live with you?" 2. The nurse asks, "What do you believe is needed to make you feel better?" 3. The nurse silently reflects about how her biases regarding poverty can influence how she assess the patient 4. The nurse uses a therapeutic and caring approach to how she interacts with the patient 3-Cultural awareness involves becoming more self-aware of your biases and attitudes about human behavior and considering these factors when you interact with patients Match the following definitions with the key terms related to intersectionality. 1. Under inclusion 2. Social inequality 3. Social location a. Groups have unequal access to resources , services, and positions b. A group has been overlooked in research and design of interventions c. One's place in society is based on membership in a social group that determines access to resources 1-B, 2-A, 3-C A nurse is preparing to perform a cultural assessment of a patient. Which of the following questions is an example of a contrast question? 1. Tell me about your ethnic background 2. Have you had this problem in the past? 3. Where do other members of your family live? 4. How different is this problem from the one you had previously? 4 How different is this problem from the one you had previously? How can a nurse work on developing cultural awareness? (select all) 1. Reflect on their past learning about health, illness, race, gender, and sexual orientation 2. Develop greater self-knowledge about personal biases 3. Recognize consciously the multiple factors that influence his or her own world view 4. Engage in an in-depth self-examination of his or her own background 1,2,3,4- Remember that developing cultural awareness is a life-long process. It is foundation of becoming culturally competent. During an encounter with an elderly patient, the nurse recognizes that a thorough cultural assessment is necessary because the patient has recently come to the US from Russia and has never been hospitalized before. The nurse wants to discuss cultural similarities between herself and the patient. Which step of the LEARN mnemonic is this? 1. Listen 2. Explain 3. Acknowledge 4. Recommend treatment 5. Negotiate agreement 3- Acknowledge When you care for a patient who does not speak English, it is necessary to call a professional interpreter. Which of the following are proper principles for working with interpreters? (select all) 1. Expect the interpreter to interpret your statements word-for-word so there is no misunderstanding by the patient 2. If you feel an interpretation is not correct, stop and address the situation directly with the interpreter 3. Pace a conversation so there is no time for the patient's response to be interpreted 4. Direct your questions to the interpreter 5. Ask the patient for feedback and clarification at regular intervals 2,3,5- You should not expect the interpreter to interpret your statements word for word. Although the interpreter must ensure that everything that was said is interpreted, they may need to use more or fewer words to convey the meaning of your conversation with a patient. Direct your questions to the patient. Look at the patient instead of the interpreter In the US, there has never been a president of Asian or Hispanic culture. This is an example of: 1. Social inequality 2. Marginalization 3. Under inclusion 4. Social location 2- Marginalization At 1200 the RN says to the CNA, " You did a good job walking Mrs. Taylor by 0930, I saw that you recorded her pulse before and after the walk. I was that Mrs. Taylor walked in the hallway barefoot. For safety, the next time you walk a patient, you need to make sure that the patient wears slippers or shoes. Please walk Mrs. Taylor again by 1500." Which characteristics of positive feedback did the RN use when talking to the nursing assistant? (select all) 1. Feedback is given immediately 2. Feedback focuses on one issue 3. Feedback identifies concrete details 4. Feedback identifies ways to improve 5. Feedback focuses on changeable things 6. Feedback is specific about what is done incorrectly only 2,3,4,5- These are characteristics of good feedback. The other options are not appropriate because the RN did not provide feedback immediately and you should give both positive feedback as well as feedback to improve the incorrectly done tasks As a nurse, you are assigned to 4 patients. Which patient do you need to see first? 1. The patient who had abdominal surgery 2 days ago who is requesting pain meds 2. A patient admitted yesterday with atrial fibrillation with decreased level of consciousness 3. A patient with a wound drain who needs teaching before discharge in the early afternoon 4. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery 2- The patient is of high priority. The patient is experiencing the physiological problem of decreased level of consciousness that is an immediate threat to the patient's survival and safety. The nurse must intervene promptly and notify the health care provider of the life threatening problem A nurse asks a CNA to help the patient in room 418 walk to the bathroom right now. The RN tells the CNA that the patient needs assistance of 1 person and a walker. The nurse also tells the CNA that the patient's oxygen can be removed while he goes to the bathroom, but to be sure that it is put back on at 2L. The nurse also instructs the CNA to make srue the side rails are up and the bed alarm is reset after the patient gets back in bed. Which of the following components of the "5 rights of delegation" were used by the RN? (select all) 1. Right task 2. Right circumstances 3. Right person 4. Right direction/communication 5. Right supervision/evaluation 1,2,3,4- The nurse delegated the task of a patient to the bathroom to the CNA, which is in the scope of a CNA's duties and responsibilities and matched the CNA skill level. The nurse did provide clear directions by describing the task and the time period to complete the task. The nurse did not use "please" and "thank you" in the request. The nurse did not ask if there were any questions. The nurse did not ask the CNA to follow up check on how the patient did or if there were any problems. The nurse did not provide appropriate monitoring, evaluation, intervention as needed, or feedback A patient asks a nurse what the patient-centered care model for the hospital means. What is the nurse's best answer? 1. "This model ensures that all patients have private rooms when they are admitted to the hospital." 2. "In this model, you and the health care team are full partners in decisions related to your health care." 3. "This model focuses on making the patient experience a good one by providing amenities such as restaurant-style food service." 4. "Patients and families sign a document providing them full access to their medical charts." 2-Patient and family centered care is based on the development of mutual partnerships between the patient, family, and healthcare team to plan, implement, and evaluated the patient's health care. The patient and family are at the center of the care and are full partners in decision making While administering medications, a nurse realized that a prescribed does of a medication was not given. The nurse acts by completing an incident report and notifying the patient's health care provider. The nurse is exercising: 1. Authority 2. Responsibility 3. Accountability 4. Decision making 3-Accountability, Nurses being answerable for their actions. It means nurses accept the commitment to provide excellent patient care and the responsibility for the outcomes of the actions in providing that. Following institutional policy for reporting medication errors demonstrate the nurse's commitment to safe patient care The staff on the nursing unit are discussing implementing interprofessional rounding. Which of the following statements correctly describe interprofessional rounding? (Select all that apply.) 1. Allows team members to share information about patients to improve care 2. Provides an opportunity for early patient discharge planning 3. Improves communication among health care team members 4. Allows each of the health care team members to identify separate patient goals 5. Allows each health care provider an opportunity to delegate a task 1,2,3- Allowing team members to share info on patients to improve care, providing an opportunity for early patient discharge planning, and improving communication amongst team members all focuses on the benefits of interprofessional rounding. This type of rounding has been found to decrease medication errors and improve quality of patient care. During interprofessional rounding all team members focus on the same patient goals After a nurse receives a change-of-shift report on his assigned patient's, he prioritizes the tasks that need to be completed. This is an example of a nurse displaying which practice? 1. Organizational skills 2. Use of resources 3. Time management 4. Evaluation 3-Time management, Completing a priority to-do list is a useful time-management skill. Change of shift report can help you sequence activities based on what you learn about the patient's conditions and the care the patient has received A nurse is teaching a patient about wound care that will need to be done daily at home after the patient is discharged. This is which priority nursing need for this patient? 1. Low priority 2. High priority 3. Intermediate priority 4. Nonemergency priority 2- High priority, Teaching patients wound care for discharge is an intermediate priority. Intermediate priorities are nonemergency, non-life-threatening actual or potential needs that the patient and family members are experiencing A RN is providing care to a patient who had abdominal surgery 2 days ago. Which task is appropriate to delegate to the CNA? 1. Helping the patient ambulate in the hall 2. Changing surgical wound dressing 3. Irrigating the NG tube 4. Providing brochures to the patients on health diet 1- Helping the patient ambulate in the hall, Assisting the patient with an activity is within the scope of the CNA. The other activities require the skill and knowledge of the RN Which task is appropriate for a RN to delegate to a CNA? 1. Explaining to the patient the preoperative preparation before the surgery in the morning 2. Administering the ordered antibiotic to the patient before surgery 3. Obtaining the patient's signature on the surgical informed consent 4. Helping the patient to the bathroom before leaving for the operating room 4-Helping the patient to the bathroom before leaving for the operating room. Assisting the patient with toileting activities is within the scope of nursing assistive duties. The other activities require the skills and knowledge of the RN Which of the following are components of interprofessional collaboration? (select all) 1. Interprofessional education does not impact the collaboration among interprofessional team members 2. Nurses are often viewed as the team leader because of their coordination of patient care 3. Effective interprofessional collaboration requires mutual respect and trust from all team members 4. Open communication improves the collaboration among the interprofessional team members 5. The goal of interprofessional collaboration is to improve the quality of patient care 2,3,4,5-The nurse plays a critical role within the team and is often viewed as the team leader through coordination of communication and patient care. Open communication, cooperation, trust, mutual respect, and understanding of team member roles and responsibilities are critical for successful interprofessional collaboration. The development of these competencies comes through interprofessional education. A change in education and team training of healthcare practitioners is needed to build effective teams to improve interprofessional A RN performs the following four steps in delegating a task to a CNA. Place the steps in the order of appropriate delegation 1. Do you have any questions about walking Mr. Malone? 2. Before you take him for his walk to the end of the hallway and back, please take and record his pulse rate 3. In the next 30 minutes please assist Mr. Malone in room 418 with his afternoon walk 4. I will make sure that I check with you in about 40 minutes to see how the patient did 3,2,4,1- The is the sequence of effective delegation. Sandy delegated the task of walking a patient to Tony, which is in the scope of his duties and responsibilities and matched to his skill level. She provided clear direction by describing the task and the time period. Sandy then told Tony that she would follow up with him to check how the patient did. By asking Tony if he had any questions she provided him an opportunity to ask questions for clarification Which example demonstrates a nurse performing the skill of evaluation? 1. The nurse explains the side effects of the new blood pressure medication ordered for the patient 2. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering the pain medication 3. After completing the teaching, the nurse observes the patient draw up and administer an insulin injection 4. The nurse changes a patient's leg ulcer dressing using aseptic technique 3- Evaluation is one of the most important aspects of clinical care coordination, involving the determination of patient outcomes. Observing a patient do a return demonstration of teaching is evaluation to ensure that the patient has understood teaching. The nurse manager from the surgical unit was awarded the nursing leadership award for practice of transformational leadership. Which of the following are characteristics or traits of transformational leadership displayed by aware winner? (select all) 1. The nurse manager regularly rounds on staff to gather input on the unit decisions 2. The nurse manager sends thank-you notes to staff in recognition of a job well done 3. The nurse manager sends memos to staff about decisions that the manger has made regarding unit policies 4. The nurse manager has an "innovation idea box" to which staff are encouraged to submit ideas for unit improvement 5. The nurse develops a philosophy of care for the staff 1,2,4- Nurse managers who practice transformational leadership are focused on change and innovation. They motivate and empower their staff with the focus on team development. The manager will spend time time on the unit with the staff sharing ideas and listening to staff input. The manager is enthusiastic about opportunities to enhance the team and shows appreciation and recognized team members for good work. The manager holds the team accountable and provides support for the team members in the stressful health care environment How to properly use therapeutic communication Never use the word "why" at the beginning of the sentence A nurse assesses patients and uses assessment findings to identify patient problems and develop an individualized plan of care. The nurse is displaying: 1. Organizational skills 2. Use of resources 3. Priority setting 4. Clinical decision making 4- Clinical decision making, Depends on the application of the nursing process. You first complete a patient assessment so you are able to make accurate judgment about the patient's nursing diagnoses and health problems. The next step is to complete a plan of care for the patient. You use critical thinking in the clinical decision process. How often do you need to check someone's restraints for skin integrity? Every 2 hours How long is an emergency restraint prescription good for, for an adult? 4 hours How long is an emergency restraint prescription good for, for someone 9 to 17? 2 hours How long is an emergency restraint prescription good for, for someone younger than 9 years old? 1 hour Dementia vs Delirium - Delirium: acute onset, physical symptoms - Dementia: insidious onset, defect in short-term memory Purpose of anti-embolic stockings Prevents vein distension Passive range of motion Motion carried out by someone else Purpose of a gait belt Maintain safety while pt is ambulating. Active range of motion Motion carried out by pt Morse Fall Scale ranges *Higher the number, the higher the risk 0 to 24: LOW Implement level I preventive fall precautions 25 to 44: MODERATE Implement level II preventive fall precautions Greater than 44: HIGH Implement level III preventive fall precautions Safety considerations for risk of fall for older adult pts - Identify safety hazards in the environment - Modify the environment as necessary - Attend defensive driving courses or courses designed for older drivers - Encourage regular vision and hearing tests - Ensure hearing aids and eyeglasses are available and functioning - Have operational smoke detectors in place - Objective document and report any signs of neglect and abuse What is death from the use of restraints considered? Sentinel event Signs and symptoms of DVT - Pain - Edema - Warmth - Erythema Nursing actions for DVT - Notify the provider immediately. - Ultrasound order - Position the client in bed with the leg elevated. - Avoid any pressure at the site of the inflammation. - Anticipate giving anticoagulants. - D-dimer Client education for DVT Avoid the following: - Crossing legs - Sitting for long periods - Wearing restrictive clothing on the lower extremities - Putting pillows behind the knees - Massaging legs - Dependent positioning How to use a cane - Hold cane on strong side - Move cane 6" - Affected leg moves 6" next to cane - Strong leg moves beyond cane and affected leg - Move cane 6" - Affected leg meets cane 2- point gait with crutches Partial weight bearing on both legs - Affected foot/ Strong side crutch forward at the same time and are even with each other 3- point gait with crutches Cannot bear weight on 1 leg - Both crutches forward standing on strong leg - Hop forward - Move both crutches forward 4- point gait on crutches Partial weight bearing on both legs - Crutch on strong leg side forward 6 to 10" - Affected foot forward, even with strong side's crutches - Crutch on affected leg side forward 6 to 10" - Strong foot forward, even with affected side's crutches Osteoporosis prevention - Eat foods that support bone health (calcium, vitamin D, protein) - Activity (weight bearing exercise) - Stop smoking - Limit alcohol consumption Abduction Movement away from the midline of the body Adduction Movement toward the midline of the body Dorsal plantar flexion Foot goes up and down while the pt is lying down. heel does not lift from the bed, just the foot bending up and down Steps for Safe Body Mechanics 1) plan lift 2) ask for help 3) widen base of support 4) bend knees 5) tighten stomach muscles 6) lift with leg muscles 7) keep load close 8) keep back straight Obstructive sleep apnea sleep disorder defined by (5+) episodes when breathing stops during sleep as a result of blockage of the airway CPAP vs BiPAP - CPAP: provides single set of pressure relief during exhale - BiPAP: two constant pressure settings for inhale and exhale Insomnia recurring problems in falling or staying asleep - usually related to disruptions in circadian rhythms or depression Narcolepsy Excessive daytime sleepiness Somnambulism sleepwalking Pharmacological therapy for better sleep in hospitals - sedatives - hypnotics Non-Pharmacological therapy for better sleep in hospitals Cognitive behavioral therapy - Muscle relaxation - Stimulus control - Sleep restriction/hygiene measures - Biofeedback and relaxation therapy First intervention for a pt who can't sleep Least invasive (non-pharmalogic) Sensory deprivation Decreased /monotonous stimuli or inability to receive/process environmental stimuli Sensory overload Too much stimuli where brain cannot respond meaningfully - Pt feels out of control Sensory deficient Sensory poverty One learns about the world without experiencing it up close, right here, right now Caring for hearing-impaired pts - teach measures to prevent hearing problems - orient person to your presence before speaking - decrease background noises before speaking - check pts hearing aids - position self so light is on your face - talk directly to the person while facing them - use pantomime or sign language as appropriate - write any ideas you cannot convey in another manner Caring for visually impaired pts -teach self-care behaviors to maintain vision &prevent blindness -acknowledge your presence in patients room -speak in normal tone of voice -explain reason for touching person before doing so -keep call light in reach -orient person to sounds in environment and to room arrangement -assist w/ ambulation by walking slightly ahead of person -stay in persons field of vision -provide diversion using other senses -indicate conversation has ended when leaving room Purpose of heparin Anticoagulant that prevents enlargement of the thrombus and further clot formation (treat and prevent DVT) Intervention when injecting heparin Subcutaneous with small doses Purpose of Zolpidem Insomnia Language development in adolescents (ages 12-20) Adolescents communicate one way with the peer group and another way with adults. Use open-ended questions to communicate and discuss sensitive issues. Types of autonomy for adolescents - Emotional autonomy: independent decision-making regarding relationships - Behavioral autonomy: ability to make independent decitions - Suggest parental guidance and input Emotional autonomy Independent decision-making regarding relationships Behavioral autonomy Ability to make independent decisions Self-concept development in adolescents - View themselves in relation to similarities with PEERS during early adolescence. - View themselves according to their UNIQUE CHARACTERISTICS as the adolescent years progress Social development in adolescents - Peer relationships develop. These relationships act as a support system for adolescents. - Best-friend relationships are more stable and longer-lasting than they were in previous years. - Parent-child relationships change to allow a greater sense of independence. What are middle adults (35 to 65 years) at risk for? Cardiovascular disease Expected integumentary changes in development of older adults (65+) - Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin - Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold temperatures - Thinning and graying of hair, as well as a sparser distribution - Thickening of fingernails and toenails Expected cardiovascular changes in development of older adults (65+) - Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infections - Reduced cardiac output - Decreased peripheral circulation - Increased blood pressure Expected neurologic changes in development of older adults (65+) - Slower reaction time - Decreased touch, smell, and taste sensations - Decline in visual acuity - Decreased ability for eyes to adjust from light to dark, leading to night blindness, which is especially dangerous when driving - Inability to hear high-pitched sounds (presbycusis) - Reduced spatial awareness Expected gastrointestinal changes in development of older adults (65+) - Decreased production of saliva - Decreased digestive enzymes - Decreased intestinal motility, which can lead to increased risk of constipation - Increased dental problems Expected muscoloskeletal changes in development of older adults (65+) - Decreased height due to intervertebral disk changes - Decreased muscle strength and tone - Decalcification of bones - Degeneration of joints Expected genitourinary changes in development of older adults (65+) - Decreased bladder capacity - Prostate hypertrophy in males - Decline in estrogen or testosterone production - Atrophy of breast tissue in females Expected endocrine changes in development of older adults (65+) - Decline in triiodothyronine (T3) production, yet overall function remains effective - Decreased sensitivity of tissue cells to insulin Expected immune changes in development of older adults (65+) - Decreased production of antibodies by B cells - Increased production of autoantibodies (antibodies against the host's body) with increased autoimmune response - Decreased core body temperature - Decreased T-cell function - Decreased stress response - Decreased response to immunizations Define Values Beliefs about the worth of something, about what matters, that acts as a standard to guide one's behavior. Values are formed during your lifetime and involve influence from the environment, family, and culture Define Ethics A systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing Define Ethical Dilemma Ethical dilemmas arise when attempted adherence to basic ethical principles results in two conflicting courses of action What is the ANA Code of Ethics? A set of principles that reflect the primary goals, values, and obligations of the profession What is HIPAA? HIPAA: Health Insurance Portability and Accountability Act Ensures that patients have a right... - To see and copy their health record - To update their health record - To request a restriction on certain uses or disclosures - To choose how to receive health information - Protects their medical history and private information What are Good Samaritan laws? Good Samaritan laws are designed to protect health practitioners when they give aid to people in emergency situations. Define ethics. The study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing. Ethics is not religion, law, custom, or institutional practices. Something being legal does not make it ethically or morally right. Define human flourishing. An effort to achieve self-actualization and fulfillment within the context of a larger community of individuals, each with the right to pursue his or her own such efforts Define ethical conduct. Practice based on professional standards of ethical conduct as well as professional values. List some virtues of nursing. - Competence - Compassionate caring - Subordination of self-interest to patient interest - Self-effacement - Trustworthiness - Intelligence - Practical wisdom - Humility - Courage - Integrity - Conscientiousness What is trustworthiness in the ethics of nursing? - When you become aware of ethical issues, you are responsible for alerting the appropriate party - When patients are not getting the care needed, you are responsible for responding within the scope of your power and responsibility - Professional nurses are competent, compassionate, collaborating advocates for patients and their families What are the goals of all laws and professional regulations of nursing? Public safety What are some of the categories of malpractice claims? - Failure to follow standards of care - Failure to use equipment in responsible manner - Failure to assess and monitor (Failure to rescue) - Failure to communicate - Failure to document - Failure to act as a patient advocate How much liability do student nurses have? - Held to same standard of care as a registered nurse - Responsible for your own acts - Responsible for being familiar with agency policies and procedures - Hospital and College can be held liable for negligence - Students carry personal professional liability insurance What are some reasons for suspending or revoking a nursing license? - Drug or alcohol abuse - Fraud - Deceptive practice - Criminal acts - Previous disciplinary actions - Gross or ordinary negligence - Physical or mental impairments, including age List some safeguards to competent practice. - Respecting legal boundaries of practice - Following institutional procedures and policies - Owning personal strengths and weaknesses - Evaluating proposed assignments - Keeping current in nursing knowledge and skills - Respecting patient rights and developing rapport with patients - Keeping careful documentation - Working within agency for management policies - Legislation varies about what authority to report to - Most states, failure to report actual or suspected abuse is a crime - Nurses are protected by law against suits from the alleges abusers What are Good Samaritan Laws? - Designed to protect health practitioners when they give aid to people in emergency situations - Every state in the USA has these laws - Laws vary so know your state - If care is provided, the expectation is that the practitioner would use good judgement to determine the emergency and give care that a reasonably prudent person with a similar background would provide What are some reporting obligations of nurses? - Child and elder abuse - Abuse of all types (physical, verbal, sexual, emotional, neglect, and abandonment) - Rape - Communicable disease What are wills, and what is the nurse's role in the will of the patient? - Describes the intentions of the individual in regard to estate management, property disposition, end of life care - Nurses may witness a will being made and sign it with them - Must determine that the person is of a sound mind - Voluntarily making the will - Sign in the presence of each other - Beneficiary doesn't usually sign the will Define care coordination. Working together to provide good care. What does quality mean in terms of health care? The right care for the right person at the right time. Nurses are on the frontline for assuring safety and quality care. What are the IOM's (Institute of Medicine) six outcomes for a new health system for the 21st century? - Safe - Effective - Efficient - Patient-centered - Timely - Equitable (Reasonable and fair to all parties) What are the three key issues to health care? - Access to Healthcare - Quality and Safety - Affordability What is PPO? Preferred provider organization. Your insurance company has a list of preferred providers, they have a relationship with the doctor so that doctor will accept that insurance, the insurance will pay more of the bill than if you go out of the network. (More accessible) What is HMO? Health maintenance organization. Coordinated care, list of doctors of all specialties who are all connected to each other, you must use those doctors, you don't have an option to go out of network. (More cost effective) What is Medicare? - Citizens over 65, elderly - Covers hospital care, extended care, home health care, and 100 days in rehab - You can get a supplement - No dental coverage - Doesn't pay for preventable medical/nursing errors - Pay deductible and monthly premium What is Medicaid? - Government program - Any age - Low income/disabled/or renal failure List some trends to watch for in health care delivery. - Changing demographics - Increasing diversity - Technology explosion - Globalization of economy of society - Educated and engaged consumers - Increasing complexity of patient care - Costs of healthcare - Effect of health policy and regulation - Shortages of key health care professionals and educators What is community-based nursing? - Care provided to people where they live, work, play, worship, and go to school (Neighborhood clinics, homes, long-term care facilities, schools, churches, prisons) - Promote health, manage illness, promote self-care (Advocate, coordinate, educate) - Requires certain qualities (Adapt to environment and be flexible, knowledgeable and skilled, autonomous and creative problem-solving and decision-making, accountable) What is continuity of care? - Process by which health care providers give appropriate, uninterrupted care and facilitate the patient's transition between different settings and levels of care - Ensures a smooth transition between ambulatory or acute care and home health care or other types of health care settings in the patient's community. - Depends on excellent communication as patients move from one caregiver or health care site to another. What is care coordination? - Care transition: a continuous process in which a patient's care shifts from being provided in one setting of care to another - Central responsibility of all health care professionals, and especially nurses - Aim: Link patients with resources in the community to enhance their well-being, improve information exchange, reduce fragmentation and duplication of services What are some essential components of discharge planning? - Nurses start planning for discharge when the patient is admitted - Assess strengths and limitations of the patient, family, or support person - Assess the environment - Implement and coordinate the plan of care - Consider individual, family, and community resources. Evaluate effectiveness of care How do you establish an effective nurse-patient relationship? - Reduce anxiety through therapeutic communication, teaching, and acceptance. - Remember that the patient has concerns and needs other than medical ones. - Communicate with the patient as an individual. - Take time to learn about the patient being admitted. - Provide for family participation in all aspects of care. What is self care, according to the ANA? - "The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth." (ANA, 2017) - Nurses have an ethical duty to care for ourselves How do you plan a course of action for self care? Formulate a plan with measurable and achievable goals, as well as specific timing for the actions you plan to take. - For example, if your self-care goal is to have more time in nature, you will set an achievable and measurable goal, such as: "I will hike in one of my favorite nearby hiking spots twice weekly over the next three months." The specificity of the plan is crucial; make it specific, measurable, and has a time frame. What are the self care vital signs? - BP = Being Present (Have I cultivated the art of being truly present in each human encounter? Does my lifestyle support this?) - T = Tracking (Am I tracking the numbers most important to my health: blood pressure, weight, blood sugar, lipid levels?) - P = Practicing health and wellness behaviors (Am I a model of healthy behaviors?) - R = Refueling (Do I get adequate sleep and find meaning, energy, and joy in many aspects of my life? When I am running on empty, how do I refuel?) What are the five steps to self care for a nurse? - Do a self care assessment - Diagnose a self care deficit - Plan a course of action - Implement the plan - Evaluate your progress