Med-Surg certification practice (CMSRN blueprint): practice questions

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At 1930, a patient is alert and oriented, with a respiratory rate of 30 and oxygen saturation of 90% on room air. At midnight, those measurements are unchanged, but breathing effort has increased and confusion has developed. Which entry best summarizes the respiratory trend?
1. Respiratory status unchanged, with no change in respiratory rate or oxygen saturation.
2. Respiratory trend cannot be determined until a decrease in oxygen saturation is recorded.
3. Respiratory status unchanged; new confusion documented separately as a behavioral finding.
4. Respiratory findings worsening, with increased breathing effort and new confusion despite unchanged oxygen saturation.
Answer: Respiratory findings worsening, with increased breathing effort and new confusion despite unchanged oxygen saturation.
Increased breathing effort can signal deterioration, and changes in consciousness can accompany respiratory compromise. The other entries either mistake unchanged measurements for stability, separate a relevant mental-status change from respiratory assessment, or incorrectly require oxygen saturation to fall before recognizing worsening.
At 1930 triage, a nurse drafts the entry "Cough present." Before completing the assessment, which details should the nurse assess and document to characterize the cough itself, rather than the broader respiratory history? Select all that apply.
1. Whether the patient uses home respiratory equipment.
2. How frequently the patient coughs.
3. How severe the cough is and what it sounds like.
4. Whether the cough produces sputum or blood.
5. Which medications the patient takes for respiratory concerns.
Answer: How frequently the patient coughs., How severe the cough is and what it sounds like., Whether the cough produces sputum or blood.
Frequency, severity, sound, and production of sputum or blood characterize the cough and make the entry more informative. Home respiratory equipment and respiratory medications belong in the broader subjective assessment, but they do not describe the cough itself.
At 0800, the nurse is reassessing diminished breath sounds and increasing crackles. Which assessment-and-documentation plan best supports comparing findings between the right and left lung fields?
1. Use the stethoscope diaphragm to move systematically side to side across all lung fields, documenting comparisons at matching levels.
2. Auscultate the entire right side and then the entire left side, documenting one overall description for each side.
3. Auscultate over the trachea, then document whether the sounds in each lung field match that reference sound.
4. Auscultate both lung bases, then use those findings to document an overall description of sounds throughout the lungs.
Answer: Use the stethoscope diaphragm to move systematically side to side across all lung fields, documenting comparisons at matching levels.
Systematic side-to-side auscultation allows direct comparison of lung sounds at the same level on both sides. Tracheal sounds are not the expected reference for every lung field, and listening only at the bases leaves other fields unassessed. One overall description per side provides less detail for matching-level comparisons.
At 2300, a nurse reviews the results for a patient admitted with acute left-sided HF: BNP was 500 pg/mL at 0800, 750 pg/mL at 1700, and 1500 pg/mL at 2300. Which documentation approach best supports evaluation of the patient's response to treatment?
1. Record the latest BNP result and classify the treatment response from that result.
2. Record current bedside findings and reserve the BNP trend for documentation of the diagnostic workup.
3. Record all three BNP values alongside current respiratory findings, edema findings, and weight.
4. Record the BNP trend alongside the admission assessment to describe the patient's current condition.
Answer: Record all three BNP values alongside current respiratory findings, edema findings, and weight.
The section recommends evaluating BNP levels together with the clinical presentation to assess treatment response. The latest value alone lacks clinical context, and the admission assessment may not represent the patient's current condition. Omitting the BNP trend from ongoing evaluation overlooks its role in monitoring response.
At 0800, a nurse reviewing an HF patient's chart notices that daily weights were obtained under different conditions. The nurse updates the care plan to make future weight measurements more comparable. Which instructions should be included? Select all that apply.
1. Schedule weight measurement in the morning.
2. Have the patient void before obtaining the weight.
3. Use whichever garments the patient is wearing that morning.
4. Use the same garments for weight measurements, or weigh the patient nude if possible.
5. Weigh before the first morning void to capture the earliest value.
Answer: Schedule weight measurement in the morning., Have the patient void before obtaining the weight., Use the same garments for weight measurements, or weigh the patient nude if possible.
The section specifies morning weighing after voiding, with the patient in the same garments or nude if possible. Weighing before voiding or allowing garments to vary does not follow the stated approach to obtaining comparable daily weights.
At 1700, after auscultating a patient with HF who has a productive cough, a nurse reviews the entry 'Cough with abnormal breath sounds.' Which revision best addresses the missing assessment detail?
1. Expand the note with sputum characteristics, using 'abnormal anterior and posterior lung sounds' to summarize auscultation.
2. Expand the note with the locations of abnormal breath sounds, using 'productive cough' to summarize the sputum assessment.
3. Expand the note with the locations of abnormal breath sounds and the sputum's color, consistency, and amount.
4. Expand the note with oxygen saturation and breathing pattern, retaining 'cough with abnormal breath sounds' as the summary.
Answer: Expand the note with the locations of abnormal breath sounds and the sputum's color, consistency, and amount.
The section specifically calls for documenting where abnormal breath sounds are heard and the sputum's color, consistency, and amount. Adding oxygen saturation and breathing pattern does not supply those missing details. The other revisions leave either the sound locations or the sputum characteristics insufficiently described.
At 08:00, a nurse reviews a report describing increased pressure required during ventricular contraction. The draft nursing note says, "Cardiac output increased." Which replacement accurately documents the reported change without substituting a different measurement?
1. Afterload increased.
2. Cardiac output increased.
3. Stroke volume increased.
4. Preload increased.
Answer: Afterload increased.
The reported change concerns the pressure required during ventricular contraction, which the section identifies as afterload. Preload concerns stretch before contraction; stroke volume and cardiac output concern blood volume, so their increases are not established by this report.
At 11:00, a nurse prepares a patient-teaching summary using a diagram that moves from ventricular filling to ventricular contraction. Which statements about the aortic and pulmonic valves should be included? Select all that apply.
1. The aortic valve closes during ventricular filling.
2. The aortic valve remains closed during ventricular contraction.
3. The pulmonic valve closes during ventricular filling.
4. The pulmonic valve opens to allow ventricular filling.
5. Both valves open during ventricular contraction.
Answer: The aortic valve closes during ventricular filling., The pulmonic valve closes during ventricular filling., Both valves open during ventricular contraction.
Both the aortic and pulmonic valves close during ventricular filling and open during ventricular contraction. Describing the pulmonic valve as opening for filling or the aortic valve as remaining closed during contraction reverses the sequence given in the section.
At 19:00 handoff, a nurse notices that a draft summary labels the blood volume ejected during one left-ventricular systolic contraction as "cardiac output per minute." Which correction preserves the measurement actually described?
1. Change the label to stroke volume and retain the description of blood ejected during one systolic contraction.
2. Change the label to afterload and describe the measurement as pressure exerted during contraction.
3. Change the label to preload and describe the measurement as ventricular stretch before contraction.
4. Keep the cardiac output label and change the description to blood pumped through the aorta each minute.
Answer: Change the label to stroke volume and retain the description of blood ejected during one systolic contraction.
Stroke volume describes blood ejected from the left ventricle during systolic contraction, so changing only the label preserves the reported measurement. Rewriting it as a per-minute volume would substitute cardiac output for the original measurement. Preload and afterload describe stretch and pressure, respectively, rather than the blood volume reported here.
At 1845, you intervene for a patient's hypoglycemic episode using the facility protocol. While preparing for the 1900 shift change, you update the nursing note. Which communication plan should you document for this event?
1. Notify the provider and include the episode in the handoff report.
2. Include the episode in handoff and notify the provider only if another episode occurs.
3. Notify the provider and leave the episode details in the chart for the incoming nurse to review independently.
4. Record the episode in the glucose monitoring record and defer further reporting until the next routine assessment.
Answer: Notify the provider and include the episode in the handoff report.
The section requires reporting a hypoglycemic episode to both the provider and the nurse receiving handoff. Provider notification alone omits handoff communication, while handoff alone makes provider notification incorrectly conditional on recurrence. Recording the event without these reports does not fulfill the stated communication requirements.
At 0800, you review the care plan for a patient with DM who is experiencing an infection. Which update best reflects the section's guidance for documenting the glucose monitoring plan?
1. Increase the frequency of blood glucose assessments during the infection.
2. Continue the existing monitoring schedule and add checks only if symptoms develop.
3. Use the most recent A1c result to decide whether additional glucose checks are needed during the infection.
4. Continue the existing schedule until a glucose result exceeds the patient's target range.
Answer: Increase the frequency of blood glucose assessments during the infection.
Infection can raise blood glucose, and the section recommends more frequent assessments because a patient with DM cannot provide the usual glucose-insulin balance. Waiting for symptoms or an above-target result does not implement that recommendation. A1c reflects glucose levels over three months rather than changes during the current illness.
At 1600, after teaching a patient with DM about the condition, meal planning, glucose monitoring, and acute complications, you complete the evaluation portion of the nursing note. Which entries best document the patient's response to education rather than only the teaching provided? Select all that apply.
1. Reviewed meal planning strategies and techniques for monitoring blood glucose.
2. Discussed how to identify hypoglycemia and hyperglycemia.
3. Explained the underlying mechanisms of diabetes and the goals for blood glucose levels.
4. Patient asked questions and actively participated in the education discussion.
5. Patient accurately explained the blood glucose monitoring instructions after teaching.
Answer: Patient asked questions and actively participated in the education discussion., Patient accurately explained the blood glucose monitoring instructions after teaching.
The section identifies patient engagement and retention of information as education outcomes to evaluate. Participation documents engagement, and accurately explaining the instructions provides evidence of retention. The other entries describe teaching activities but do not show how the patient responded or what the patient retained.
At 14:10, a 16-year-old patient reports sudden, severe scrotal pain and nausea. The nurse observes scrotal swelling and suspects testicular torsion. Which entry best documents the immediate care plan?
1. Arrange ultrasound and tumor-marker testing to investigate possible testicular cancer.
2. Arrange scrotal ultrasound to characterize a possible testicular mass before contacting the provider.
3. Contact the provider immediately for urgent imaging and possible surgical intervention.
4. Reassess the patient's pain before determining whether provider notification is needed.
Answer: Contact the provider immediately for urgent imaging and possible surgical intervention.
Suspected testicular torsion requires immediate provider contact, imaging, and possible surgery to restore blood flow. Reassessment before notification delays urgent intervention, while tumor-marker testing and mass characterization address a cancer workup rather than the suspected emergency.
At 09:00, a nurse prepares the preoperative teaching plan for a 24-year-old patient scheduled for removal of one testicle because of cancer. The patient says, "I haven't decided whether I want children." Which entries belong in the teaching plan? Select all that apply.
1. Discuss the potential effect of orchiectomy on future fertility.
2. Explain the option of sperm banking before orchiectomy.
3. Schedule the initial sperm-banking discussion after recovery from surgery.
4. Explain that retaining one testicle makes fertility-preservation counseling unnecessary.
5. Defer fertility counseling until the patient decides whether to have children.
Answer: Discuss the potential effect of orchiectomy on future fertility., Explain the option of sperm banking before orchiectomy.
The source recommends counseling about potential fertility effects and offering sperm banking before orchiectomy, even when future parenthood is not yet a priority. Deferring either discussion misses the preoperative opportunity to provide a sperm sample. Although the remaining testicle often compensates, it may not function adequately, so its presence does not eliminate the need for counseling.
At a 15:00 follow-up visit for erectile dysfunction, a patient reports following the prescribed medication and lifestyle plan but still being unable to maintain an erection. Which assessment-and-plan entry best reflects the reported treatment response?
1. Treatment effective based on adherence; continue the current plan.
2. Patient reports no improvement in sexual function; further investigation and possible specialist referral are warranted.
3. Patient reports persistent symptoms; limit further evaluation to psychological screening.
4. Treatment response cannot be evaluated until blood tests establish the diagnosis of erectile dysfunction.
Answer: Patient reports no improvement in sexual function; further investigation and possible specialist referral are warranted.
The source evaluates treatment effectiveness through the patient's reported sexual function, and lack of improvement warrants further investigation and possible specialist referral. Adherence alone does not establish effectiveness, and blood tests investigate underlying causes rather than establish the ED diagnosis. Psychological screening may contribute to assessment, but it should not replace broader investigation of ineffective treatment.
At 0900, a nurse observes a mouth lesion. The patient reports that it has not healed for 2 weeks but is not painful. Which documentation and follow-up plan is best?
1. Document oral cancer based on the lesion's duration; request provider confirmation of the diagnosis.
2. Document the lesion, its reported duration, and the absence of pain; report the findings to the provider.
3. Document a painless mouth lesion and provide oral-care teaching; notify the provider if pain develops.
4. Document the lesion and its duration; reassess at the next visit before deciding whether to report it.
Answer: Document the lesion, its reported duration, and the absence of pain; report the findings to the provider.
A lesion that has not healed for 2 weeks raises suspicion for oral cancer even when painless, so the findings should be accurately documented and reported. Waiting for pain or another visit delays the follow-up described in the section. The findings support further evaluation, not documentation of a confirmed cancer diagnosis.
At 1000, a patient reports jaw pain that began earlier this week, occurs daily, and worsens with jaw clenching during stress. The nurse is documenting the history before examining jaw movement or providing teaching. Which entries are supported at this point? Select all that apply.
1. Jaw pain has improved following stress-management teaching.
2. Patient reports jaw clenching during stress makes the pain worse.
3. Assessment confirms temporomandibular disorder caused by stress.
4. Patient reports jaw pain began earlier this week and occurs daily.
5. Jaw range of movement is within normal limits.
Answer: Patient reports jaw clenching during stress makes the pain worse., Patient reports jaw pain began earlier this week and occurs daily.
The supported entries record the reported onset, frequency, and aggravating factor, which the section identifies as focused assessment information. The other entries infer a confirmed diagnosis, a response to teaching, or an examination result that has not been established.
A patient receiving treatment for oral cancer has the care-plan goal, "By 1800, the patient will report less mouth pain." At 1800, the patient reports no decrease in pain. Which entry best documents the evaluation and next step?
1. Pain-relief goal not met by the deadline; modify the goal and interventions based on the evaluation.
2. Pain-relief goal not met; extend the deadline and continue the same interventions without revision.
3. Pain-relief goal completed because planned nursing interventions were performed; continue routine monitoring.
4. Pain-relief goal remains pending; defer evaluation until the cancer treatment course is completed.
Answer: Pain-relief goal not met by the deadline; modify the goal and interventions based on the evaluation.
The section directs the nurse to evaluate goal achievement by the deadline and modify goals and interventions when the goal is not met. Simply extending the deadline or postponing evaluation leaves the unsuccessful plan unchanged. Completing interventions does not establish that the patient's pain-relief goal was achieved.
At the end of a cardiology clinic visit, you review the patient's blood pressure measurements from the past three visits. They have gradually risen to above-normal values. Which assessment entry best supports an individualized plan of care?
1. Blood pressure is above normal today; another visit is needed before the existing measurements can be assessed for a pattern.
2. Blood pressure is above normal today; assessment is based on the current reading without comparison to previous visits.
3. Blood pressure readings have increased; interpretation of these findings will be deferred until a medical diagnosis is established.
4. Blood pressure has gradually risen across three visits to above-normal values; this unexpected trend will inform the care plan.
Answer: Blood pressure has gradually risen across three visits to above-normal values; this unexpected trend will inform the care plan.
The assessment should recognize the unexpected pattern across visits and use it to guide individualized care. Considering only today's reading misses the trend, while waiting for another visit or a medical diagnosis unnecessarily postpones analysis of data already available.
At 0800, you begin an admission assessment. The patient and a family caregiver are available, and you can access the medical record. Which approaches should you use to build the assessment documentation? Select all that apply.
1. Gather relevant information from the patient's medical record.
2. Gather relevant information from the family caregiver.
3. Use only the patient and medical record as sources, excluding caregiver information from the assessment.
4. Include information reported by the patient alongside physical assessment findings.
5. Limit the assessment to physical findings, saving the patient's reported concerns for a later care-plan review.
Answer: Gather relevant information from the patient's medical record., Gather relevant information from the family caregiver., Include information reported by the patient alongside physical assessment findings.
The section identifies the patient, medical record, family members or caregivers, and physical findings as assessment sources. Restricting the entry to physical findings leaves out subjective information, and excluding the caregiver omits another source explicitly included in the assessment process.
At 1400, a patient with previously diagnosed hypertension arrives in the emergency department reporting 10/10 chest pain. You are updating the prioritized problems in the care plan. Which entry best reflects the patient's current situation?
1. Retain the previous hypertension-focused priorities until a new medical diagnosis is confirmed.
2. List hypertension and the chest-pain concern without ranking them until more assessment data are available.
3. Keep hypertension as the first priority because it is an established diagnosis; add chest pain below it.
4. Prioritize the potential myocardial infarction over treatment of the underlying hypertension.
Answer: Prioritize the potential myocardial infarction over treatment of the underlying hypertension.
The patient's current presentation changes the priorities: the potential myocardial infarction takes precedence over the underlying hypertension. Keeping the established diagnosis first, leaving the problems unranked, or waiting for confirmation fails to apply the section's situation-based prioritization.
Near the end of your shift, you evaluate a patient after prescribed pain medication and find that the pain has not been relieved. You document the patient's response. Which care-plan updates are supported by the section? Select all that apply.
1. Document persistent pain but leave the interventions unchanged for the next shift to evaluate.
2. Revise the plan to include advocating for a change in the medication order.
3. Use completion of the prescribed medication administration as the evaluation of the pain outcome.
4. Revise the plan to include a nonpharmacological approach, such as position change or distraction.
5. Update the nursing diagnosis to reflect persistent pain without revisiting the plan or interventions.
Answer: Revise the plan to include advocating for a change in the medication order., Revise the plan to include a nonpharmacological approach, such as position change or distraction.
When prescribed medication does not relieve pain, the section directs the nurse to revisit the plan and add interventions, including advocating for an order change or using nonpharmacological methods. Completing an intervention is not evidence that the outcome was achieved. Recording persistent pain, deferring changes, or revising only the diagnosis does not make the needed adjustment to the pain-management plan.
During an assessment, a patient with dementia says, "I do not take any medications." The chart lists several prescriptions, and the nurse knows that a medication was administered earlier that day. Which entry best reflects critical thinking about these conflicting data?
1. Patient reports taking no medications despite listed prescriptions and medication administration earlier today; cognitive impairment may limit medication recall.
2. Patient takes all medications listed in the chart; medication history obtained from the record because the patient's recall is unreliable.
3. Patient reports taking no medications; previously prescribed medications appear to have been discontinued.
4. Patient denies medication use; discrepancy indicates that prescribed medications are not being taken as directed.
Answer: Patient reports taking no medications despite listed prescriptions and medication administration earlier today; cognitive impairment may limit medication recall.
The correct entry preserves the conflicting information and recognizes that dementia may limit the patient's reliability as a historian. Neither discontinuation nor failure to take medications as directed is established by the discrepancy. The chart and one known administration also do not establish that the patient takes every listed medication.
During Mr. Chen's admission assessment for shortness of breath, he reports being unable to walk down his driveway to get the mail, gaining two pounds in three days, weakness, low motivation, and trouble sleeping. His record lists diabetes, hypertension, blood pressure medication, insulin, and a diuretic. The nurse observes bilateral foot swelling and a resting respiratory rate of 24 breaths/minute. Which entries belong in a summary that integrates these data without overstating conclusions? Select all that apply.
1. Current assessment findings confirm heart failure as the cause of the patient's shortness of breath.
2. Activity limitation attributed to the patient's reported lack of motivation.
3. Patient reports a two-pound weight gain in three days and inability to walk down his driveway to get the mail.
4. Medical record lists diabetes, hypertension, and prescriptions for blood pressure medication, insulin, and a diuretic.
5. Swelling observed in both feet; respiratory rate 24 breaths/minute at rest.
Answer: Patient reports a two-pound weight gain in three days and inability to walk down his driveway to get the mail., Medical record lists diabetes, hypertension, and prescriptions for blood pressure medication, insulin, and a diuretic., Swelling observed in both feet; respiratory rate 24 breaths/minute at rest.
The summary should bring together patient reports, examination findings, and medical-record information. The account identifies acute kidney injury or heart failure as possible explanations rather than confirming heart failure, and it does not establish low motivation as the cause of the patient's activity limitation.
During Mrs. Kline's annual visit, she reports nausea since the previous night and uncomfortable chest pressure. She appears pale and clammy, has lower-than-expected blood pressure and a somewhat elevated heart rate, and becomes unsteady when standing. Her temperature, respiratory rate, and O2 are normal, and medication reconciliation remains unfinished. Which entry best captures the nurse's immediate assessment priority?
1. Medication reconciliation prioritized to complete data collection before deciding whether immediate provider evaluation is needed.
2. Routine assessment continued because temperature, respiratory rate, and O2 are normal; remaining symptoms to be reviewed afterward.
3. Annual check-up deferred because of current symptoms and assessment findings; Dr. Richards requested to evaluate the patient now.
4. Symptoms attributed to the patient's reported indigestion; provider update planned after medication reconciliation.
Answer: Annual check-up deferred because of current symptoms and assessment findings; Dr. Richards requested to evaluate the patient now.
The nurse in the account prioritizes the current symptoms, pauses the annual check-up, and requests the provider immediately. The normal measurements do not outweigh the other concerning findings in this case, while accepting indigestion or completing routine tasks first would delay the priority response described.
After identifying Mr. Chen as needing the provider's priority attention, the nurse reviews her assessment documentation to learn from how she reached that decision. Which approaches would best evaluate her clinical judgment rather than merely check documentation completion or repeat data collection? Select all that apply.
1. Repeat medication reconciliation as the main way to evaluate how well the nurse reached the priority decision.
2. Ask colleagues to review the reasoning and provide feedback on the decisions made.
3. Use completion of the assessment documentation as the main measure of the quality of the clinical reasoning.
4. Judge the reasoning mainly by whether the provider shared the nurse's concern about the patient.
5. Review where connections among the medical history, patient reports, and examination findings were strong or weak.
Answer: Ask colleagues to review the reasoning and provide feedback on the decisions made., Review where connections among the medical history, patient reports, and examination findings were strong or weak.
The section describes evaluating clinical judgment by identifying strengths and weaknesses and seeking colleagues' feedback. Documentation completion and provider agreement alone do not examine how the nurse interpreted the data, while repeating medication reconciliation verifies information rather than directly reviewing the reasoning process.
At ED intake, a patient reports chest pain radiating to the left arm and rates it 8/10. You observe diaphoresis and measure a heart rate of 111 bpm. Which entry most accurately documents these findings without adding assumptions?
1. Chest pain 8/10, objectively confirmed by diaphoresis and HR 111 bpm.
2. Patient reports chest pain radiating to the left arm, rated 8/10; patient is diaphoretic; HR 111 bpm.
3. Chest pain with tachycardia and diaphoresis, likely myocardial infarction.
4. Patient reports chest pain, sweating, and a rapid heartbeat; pain rated 8/10.
Answer: Patient reports chest pain radiating to the left arm, rated 8/10; patient is diaphoretic; HR 111 bpm.
The correct entry identifies pain as the patient's report and preserves the nurse's observed and measured findings. The other entries infer an unconfirmed diagnosis, attribute observed findings to the patient, or present a subjective pain rating as objectively confirmed.
At 14:00, you complete an ED assessment and have an opportunity to document without delaying patient care. The patient will have additional encounters during the visit. Which documentation approach best follows the section?
1. Save the assessment findings for an end-of-shift entry so the full course of care can be summarized.
2. Wait for the next assessment and document only the latest findings to avoid duplicate information.
3. Wait until the care plan is finalized so the assessment and plan can be entered together.
4. Document this assessment now, then document later encounters near their occurrence and in chronological order.
Answer: Document this assessment now, then document later encounters near their occurrence and in chronological order.
Documentation should follow the order of encounters and be completed as close as possible to when they occur. Waiting for shift end or a finalized plan unnecessarily delays documentation, while recording only the latest assessment leaves a gap in the encounter record.
At 15:00, you finish providing nursing education, discussing advance directives, and confirming the patient's language preference. You also complete medication reconciliation. Your draft note contains only assessment findings. Which revisions are appropriate? Select all that apply.
1. Document that medication reconciliation was performed.
2. Add the nursing education provided during the encounter.
3. Add the patient's language preference and the discussion of advance directives.
4. Include the advance-directive discussion only if the patient completed a signed directive.
5. Include medication reconciliation only if it resulted in a medication change.
Answer: Document that medication reconciliation was performed., Add the nursing education provided during the encounter., Add the patient's language preference and the discussion of advance directives.
The section includes nursing education, advance-directive discussions, language preference, and medication reconciliation among the communications and activities nurses should document. It does not make documentation of the discussion dependent on a signed directive or documentation of reconciliation dependent on a medication change.
At 16:20, a minor needs emergency care, and the parent is available only by telephone. You are arranging verbal consent and its documentation. Which actions meet the telephone-consent process described in the section? Select all that apply.
1. Use a nursing narrative describing the call instead of obtaining witness signatures on the consent form.
2. Have the two witnesses obtain matching consent statements from the parent in separate calls.
3. Arrange for two witnesses to listen to the parent's consent simultaneously.
4. Have both witnesses sign the consent form indicating that consent was received by telephone.
5. Have one witness hear the call and a second witness verify the first witness's written account afterward.
Answer: Arrange for two witnesses to listen to the parent's consent simultaneously., Have both witnesses sign the consent form indicating that consent was received by telephone.
The section requires two witnesses to hear telephone consent simultaneously and sign the consent form indicating how consent was received. Reviewing another witness's account or making separate calls does not meet the simultaneous-listening requirement, and a narrative alone does not replace the required signatures.
At 0900, a nurse reviews a patient’s history before completing the assessment. The patient has had hypertension for 18 months, requires ongoing medical attention, and reports no limitations in activities of daily living (ADLs). Which assessment entry best applies the section’s definition of chronic disease?
1. Chronic disease requiring ongoing medical attention, with no reported ADL limitations.
2. Chronic disease classification deferred until the patient’s emotional response is assessed.
3. Chronic illness rather than chronic disease because the patient remains independent in ADLs.
4. Chronic disease classification deferred because ADL limitations have not been established.
Answer: Chronic disease requiring ongoing medical attention, with no reported ADL limitations.
The condition has lasted at least 1 year and requires ongoing medical attention, so ADL limitations are not also required. Preserved independence neither prevents classification as chronic disease nor makes chronic illness a replacement classification. Emotional responses describe the experience of chronic illness but are not required to identify chronic disease.
During a 1300 assessment, a patient diagnosed with arthritis 2 years ago reports frustration, difficulty completing daily activities, and a belief that the condition is a test of faith. The nurse is documenting the patient’s experience of chronic illness. Which entries capture that lived experience rather than simply identify or describe the underlying disease? Select all that apply.
1. Reports that arthritis makes daily activities difficult.
2. Duration of diagnosed condition: 2 years.
3. Describes the condition as a test of faith.
4. Reports frustration about living with arthritis.
5. Medical diagnosis: arthritis.
Answer: Reports that arthritis makes daily activities difficult., Describes the condition as a test of faith., Reports frustration about living with arthritis.
Chronic illness includes the patient’s emotions, beliefs, and the condition’s effects on daily life, so frustration, difficulty with activities, and the test-of-faith belief belong in this description. The diagnosis and duration describe the disease itself rather than how this patient experiences living with it.
At 1600, a patient with chronic disease says, “Spiritual rituals help me cope. I want that considered when we discuss treatment.” The nurse is preparing a handoff note. Which entry best reflects the section’s approach to cultural beliefs and patient-centered care?
1. Patient’s spiritual beliefs may interfere with participation in treatment.
2. Patient’s spiritual preferences noted for support discussions, separate from treatment planning.
3. Patient values spiritual rituals for coping and wants this preference considered in treatment discussions.
4. Patient prefers spiritual rituals instead of medical treatment.
Answer: Patient values spiritual rituals for coping and wants this preference considered in treatment discussions.
The correct entry reflects the patient’s stated preference without judgment and keeps that preference relevant to treatment discussions. The patient has not said that rituals replace medical treatment or interfere with participation. Separating the preference from treatment planning overlooks the section’s emphasis on care that considers the individual’s beliefs and needs.
At 2:00 p.m., you finish a follow-up home visit. Changes in the patient's health status led you and the patient to revise the care plan. Which documentation approach best supports continuity of care?
1. Document the interventions completed today and communicate the revised goals verbally to the team.
2. Document the current assessment findings and leave the existing care plan unchanged until the next visit.
3. Describe the revisions in a message to the primary care provider while retaining the original care plan.
4. Update the care plan with the revised goals, interventions, expected outcomes, and changes made during this visit.
Answer: Update the care plan with the revised goals, interventions, expected outcomes, and changes made during this visit.
The section specifically calls for documenting care-plan goals, interventions, expected outcomes, and changes at subsequent visits. Assessment findings, verbal communication, or a separate provider message do not replace updating the care plan to reflect the revisions.
At 8:30 a.m., you review the medication regimen before a home visit. It lists prescribed medications, but the patient also reports currently using an over-the-counter product and a home remedy. Which actions would make the documented regimen consistent with the section? Select all that apply.
1. Wait to add either product until the patient reports a side effect.
2. Record both products only under lifestyle information rather than in the medication regimen.
3. Keep the regimen limited to medications listed by the referring provider.
4. Add the over-the-counter product to the medication regimen.
5. Add the home remedy to the medication regimen.
Answer: Add the over-the-counter product to the medication regimen., Add the home remedy to the medication regimen.
The medication regimen includes all medications currently taken, explicitly including over-the-counter medications and home remedies. Restricting it to the referral list or placing these products only elsewhere leaves the regimen incomplete. Their inclusion does not depend on whether side effects occur.
At 11:00 a.m., you are documenting a home-care plan after discussing food preparation with the patient. The proposed approach does not fit the resources available in the home, and the patient has requested a different approach. What should the care-plan entry reflect?
1. The agency's usual food-preparation approach, with additional education to help the patient follow it.
2. The original approach, with the patient's concerns documented for consideration at a later visit.
3. An individualized approach developed with the patient that fits the home environment, available resources, and personal preferences.
4. The original approach, with a goal for the patient to obtain the resources needed to carry it out.
Answer: An individualized approach developed with the patient that fits the home environment, available resources, and personal preferences.
The section directs nurses to tailor care plans to the patient's home environment, resources, and preferences, with the patient actively participating. Deferring the concerns or relying on a standard approach leaves the current mismatch unresolved. Expecting the patient to obtain resources preserves the original plan rather than adapting it to the patient's circumstances.
At 0700 before surgery, the nurse finds that the procedure and site listed in the chart match the surgical consent. The patient has not yet described the planned surgery. Which action best completes the procedure-verification documentation?
1. Read the listed procedure aloud, ask whether it sounds correct, and document the patient's agreement.
2. Document that the procedure and site are verified because the chart and surgical consent agree.
3. Ask the patient to describe the surgery and site in their own words, then document whether the description matches the chart and consent.
4. Ask the patient to identify the surgical site, then document that both the site and procedure are confirmed.
Answer: Ask the patient to describe the surgery and site in their own words, then document whether the description matches the chart and consent.
The patient's own description provides a safety check against the documented procedure and site. Agreement with a procedure read aloud does not provide the same independent description. Matching paperwork alone omits the patient's account, while identifying only the site does not confirm the procedure.
During a preadmission call 10 days before surgery, a patient reports taking no prescription medications but using over-the-counter aspirin and an herbal sleep supplement. Which entries belong in the medication assessment and education plan? Select all that apply.
1. Plan to instruct the patient to stop aspirin exactly 10 days before surgery as a standard requirement.
2. Record 'No current medications' because the patient has no prescriptions.
3. Record the patient's aspirin use in the medication history.
4. Plan to discuss whether over-the-counter medicines and supplements need to be stopped or changed.
5. Record the patient's herbal sleep supplement use.
Answer: Record the patient's aspirin use in the medication history., Plan to discuss whether over-the-counter medicines and supplements need to be stopped or changed., Record the patient's herbal sleep supplement use.
The assessment and education must include over-the-counter medications and supplements, including discussion of possible changes before surgery. Recording no medications would omit the reported aspirin and supplement use. The source describes stopping aspirin for up to 10 days as a possible surgeon request that depends on the reason for aspirin therapy, not a universal instruction.
At 0900 during preadmission education, a patient is in a great deal of pain, appears distracted, and says, 'I cannot focus on these instructions.' The nurse has reviewed the planned topics. Which entry best documents the patient's current education needs?
1. Readiness to learn adequate; attention to instructions limited by pain.
2. Preoperative education completed because all planned topics were reviewed.
3. Pain and distraction limiting readiness to learn; further education needed when pain is controlled and the patient is more relaxed.
4. Preoperative education completed; postoperative nurses to reinforce the instructions.
Answer: Pain and distraction limiting readiness to learn; further education needed when pain is controlled and the patient is more relaxed.
The source identifies pain and distraction as barriers to understanding, so the entry should reflect limited readiness and the need for further education. Reviewing every topic or planning postoperative reinforcement does not establish that preoperative education is complete. Describing readiness as adequate contradicts the patient's stated inability to focus.
At 1900, a patient with a back injury reports pain for eight months: "It never completely goes away. Some movements make it worse, and others make it less intense." Which description best represents the overall pain pattern in the assessment note?
1. Chronic back pain characterized by brief breakthrough episodes.
2. Intermittent chronic back pain associated with movement.
3. Recurrent acute back pain associated with movement.
4. Constant chronic back pain with movement-related changes in intensity.
Answer: Constant chronic back pain with movement-related changes in intensity.
Eight months supports chronic pain, and continuous pain remains constant even when its intensity varies. Intermittent pain comes and goes, rather than remaining present. Recurrent acute pain and brief breakthrough episodes do not accurately describe the ongoing pattern reported here.
At 0900, a patient following limb amputation reports burning pain: "It feels like it is in the foot that was removed, not at the incision." Which statements accurately represent this report in the pain-assessment note? Select all that apply.
1. Burning incisional pain localized to the amputation site.
2. Referred pain originating in a different, intact body region.
3. Neuropathic pain associated with limb amputation.
4. Pain perceived in the missing foot, consistent with phantom pain.
5. Somatic nociceptive pain arising in the remaining limb's tissues.
Answer: Neuropathic pain associated with limb amputation., Pain perceived in the missing foot, consistent with phantom pain.
The section identifies pain perceived in a missing body part as phantom pain, a type of neuropathic pain. Referred pain would attribute the pain to another location, which this report does not establish. The remaining-tissue and incisional descriptions assign a source or location that the patient did not report.
At 1400, a patient with rheumatoid arthritis reports a sudden, brief increase in otherwise controlled chronic pain. The pain then returns to its previous level. The patient cannot identify a trigger, and the assessment has not established one. Which entry best reflects the available information?
1. Brief breakthrough pain episode; no trigger identified.
2. Acute pain caused by a new injury rather than breakthrough pain.
3. Breakthrough pain caused by the regular pain medication wearing off.
4. Stress-related breakthrough pain despite the regular medication regimen.
Answer: Brief breakthrough pain episode; no trigger identified.
A sudden, short-lived increase in pain can be breakthrough pain even when no cause is known. The report does not establish medication wearing off, a new injury, or stress, so the other entries assign unsupported causes.
At shift handoff, a patient receiving palliative care for cancer pain reports that medication provides relief for four hours, although doses are prescribed every six hours. You have notified the provider and requested a review; no new order has been received. Which entry best documents the situation?
1. Patient reports pain relief lasting four hours with the prescribed six-hour regimen. Provider notified; medication-order review requested, with no new order received.
2. Current six-hour pain regimen continued; comfort needs reviewed with the provider.
3. Pain relief lasts four hours; medication interval changed to every four hours based on the patient's response.
4. Pain medication ineffective; provider notified that a stronger medication is required.
Answer: Patient reports pain relief lasting four hours with the prescribed six-hour regimen. Provider notified; medication-order review requested, with no new order received.
The correct entry records the patient's response and accurately distinguishes a request from a new order. Changing the interval would imply an order not yet received, while the general comfort note omits the limited duration of relief. Calling the medication ineffective and requiring a stronger medication overstates the findings.
During today's shift, you observe that a patient receiving palliative care has more pain in one position than another. The patient also has difficulty participating in physical therapy when pain medication is not administered thirty minutes to an hour beforehand. Which documentation and communication actions should you include in the handoff process? Select all that apply.
1. Document which positions increase pain and communicate this information to nurses, nursing assistants, and the physical therapy team.
2. Document the observed relationship between pain-medication timing and the patient's ability to participate in therapy.
3. Communicate the need for pain medication before therapy to opposite-shift nurses and the physical therapy team.
4. Record the pretherapy medication timing in the nursing note and rely on the physical therapy team to find it during routine chart review.
5. Include the positioning concerns in verbal handoff only, since they do not require a medication-order change.
Answer: Document which positions increase pain and communicate this information to nurses, nursing assistants, and the physical therapy team., Document the observed relationship between pain-medication timing and the patient's ability to participate in therapy., Communicate the need for pain medication before therapy to opposite-shift nurses and the physical therapy team.
The section requires both documentation of these observations and communication to the team members involved in care. Charting alone does not replace communication with physical therapy, and verbal handoff alone leaves the positioning concerns undocumented.
Before discharge home, you review bathing and dressing assistance with a patient's wife, who will participate in the patient's palliative care. She says she understands. Which next step best supports a note describing her ability to provide the care?
1. Ask her to describe the care verbally, then document that she can perform it without observing a demonstration.
2. Ask her to re-demonstrate the care while explaining each step, then document what she demonstrates and explains.
3. Review the instructions again, then document that she attended the complete teaching session.
4. Ask whether she has questions, then document understanding if she has none.
Answer: Ask her to re-demonstrate the care while explaining each step, then document what she demonstrates and explains.
The section specifically calls for family caregivers to re-demonstrate care with a verbal walkthrough. Agreement, absence of questions, and attendance document participation rather than demonstrated ability. A verbal explanation alone omits the re-demonstration required by the source.
At 1600, a nurse is preparing a handoff about a recent immigrant from China who has remained guarded over several appointments. The nurse has not established the reason for this behavior. Which entry best reflects cultural humility?
1. Patient remains guarded during visits; education is needed to improve willingness to participate in care.
2. Patient remains guarded during visits; the reason for this behavior has not been established.
3. Patient remains guarded during visits, reflecting a cultural preference for limited discussion with nurses.
4. Patient remains guarded during visits; repeated encounters have not resolved mistrust of the care team.
Answer: Patient remains guarded during visits; the reason for this behavior has not been established.
The correct entry describes the patient's behavior without assigning an explanation the nurse has not established. The other entries assume a cultural preference, mistrust, or unwillingness to participate, rather than maintaining a nonjudgmental attitude toward behavior that is not yet understood.
At 1000, a nurse is updating the communication plan before discussing a patient's cultural experiences and health-care needs. Which planned approaches should the nurse include to reflect respectful communication? Select all that apply.
1. Use a brief yes-or-no checklist instead of inviting the patient to describe cultural experiences.
2. Document customary preferences for the patient's cultural group when individual preferences are not volunteered.
3. Listen actively to understand the patient's account of their health-care needs.
4. Use empathetic responses when the patient describes cultural experiences.
5. Use open-ended questions to explore the patient's cultural experiences and care needs.
Answer: Listen actively to understand the patient's account of their health-care needs., Use empathetic responses when the patient describes cultural experiences., Use open-ended questions to explore the patient's cultural experiences and care needs.
The section identifies active listening, open-ended questions, and empathetic responses as ways to understand the patient's experiences and needs. Filling gaps with group-based preferences substitutes assumptions for individual input, while replacing discussion with a yes-or-no checklist limits the open-ended exploration described in the section.
At 1410, you page Dr. Lee about urine output of 20 mL over the past 2 hours. You have not yet spoken with Dr. Lee or received an order. Which entry most clearly documents the communication that has actually occurred?
1. 1410: Urine output of 20 mL over past 2 hours; provider contacted.
2. 1410: Dr. Lee aware of urine output of 20 mL over past 2 hours; awaiting orders.
3. 1410: Paged Dr. Lee regarding urine output of 20 mL over past 2 hours.
4. 1410: Discussed urine output of 20 mL over past 2 hours with Dr. Lee; no new orders received.
Answer: 1410: Paged Dr. Lee regarding urine output of 20 mL over past 2 hours.
The page entry identifies the time, provider, information sent, and communication method without implying a response. 'Aware' and 'discussed' claim more than sending a page establishes. 'Provider contacted' is less useful because it leaves the provider's identity and method of communication unclear.
At 0830, a patient declines a shower, reporting fatigue. You offer a seated wash at the bedside and assist with washing the patient's face and upper body; the patient declines the remaining hygiene care. You plan to reoffer care after rest. Which statements can be combined into an accurate note about this encounter? Select all that apply.
1. 0830: Declined all hygiene care because of fatigue.
2. 0830: Hygiene care completed with assistance at bedside.
3. Offered seated wash at bedside; assisted with washing face and upper body.
4. Declined remaining hygiene care at this time; plan to reoffer after rest.
5. 0830: Declined shower, reporting fatigue.
Answer: Offered seated wash at bedside; assisted with washing face and upper body., Declined remaining hygiene care at this time; plan to reoffer after rest., 0830: Declined shower, reporting fatigue.
The selected statements identify the care declined, the patient's stated reason, the alternative offered, the assistance actually provided, and the future plan. 'Hygiene care completed' overstates what was done, while 'declined all hygiene care' contradicts the care the patient accepted.
At 0015 on 09/12/2026, you realize you did not chart assisting a patient to ambulate 50 feet with a walker at 1930 on 09/11/2026. You accurately recall that the patient denied dizziness during ambulation. Which entry best distinguishes when the care occurred from when you documented it?
1. 09/12/2026 0015: Late entry for previous shift: Assisted patient to ambulate 50 feet with walker. Patient denied dizziness during ambulation. J. Lee, RN.
2. 09/12/2026 0015: Assisted patient to ambulate 50 feet with walker. Patient denied dizziness during ambulation. J. Lee, RN.
3. 09/11/2026 1930: Assisted patient to ambulate 50 feet with walker. Patient denied dizziness during ambulation. J. Lee, RN.
4. 09/12/2026 0015: Late entry for care provided 09/11/2026 at 1930: Assisted patient to ambulate 50 feet with walker. Patient denied dizziness during ambulation. J. Lee, RN.
Answer: 09/12/2026 0015: Late entry for care provided 09/11/2026 at 1930: Assisted patient to ambulate 50 feet with walker. Patient denied dizziness during ambulation. J. Lee, RN.
The correct entry explicitly separates the documentation date and time from the care date and time. Using only the previous evening's timestamp makes the entry appear to have been written then, while using only the current timestamp leaves the care timing unclear. Labeling the note 'Late entry for previous shift' acknowledges the delay but omits the known care date and time.
At 0920 on 09/12/2026, you discover that your note entered at 1810 on 09/11/2026 identifies the left forearm, but the dressing you reinforced was on the right forearm. You can accurately support this correction. Which actions should you take? Select all that apply.
1. Enter 'Chart fixed' with the current date and time as the entire correction note.
2. Ask a supervisor to authenticate the correction instead of authenticating it yourself.
3. Use the approved correction workflow to identify the original note and explain the location error while keeping the original entry intact.
4. Authenticate the correction with your own credentials.
5. Replace 'left forearm' with 'right forearm' in the original note without retaining the earlier version, so the chart contains only the accurate location.
Answer: Use the approved correction workflow to identify the original note and explain the location error while keeping the original entry intact., Authenticate the correction with your own credentials.
The correction should identify the earlier note, explain the specific change, preserve the original entry, and carry your own authentication. Overwriting removes the correction history, while 'Chart fixed' does not identify what changed or which entry was corrected. A supervisor's authentication instead of your own does not follow the article's instruction to authenticate your addition with your own credentials.
At the end of your shift, you notice that your chart entry after a patient’s fall includes “Incident report completed.” You want to address that wording. What is the best next step?
1. Copy the incident report into the chart so the existing reference points to a complete account.
2. Delete only the report reference, leaving the documented assessment and care unchanged.
3. Replace the original entry with a new version that contains the same clinical facts but omits the report reference.
4. Ask about the facility’s approved amendment process without erasing or overwriting the entry.
Answer: Ask about the facility’s approved amendment process without erasing or overwriting the entry.
The article directs you to ask about the approved amendment process rather than erasing or overwriting an entry. Deleting the phrase or replacing the original entry conflicts with that guidance, while copying the report into the chart further mixes the safety report with the clinical record.
At 1012, you observed an infusion pump’s screen go blank and the infusion stop. At 1015, you resumed the infusion using a replacement pump at the ordered rate and verified its settings against the active order. At 1025, the replacement pump is operating and the IV site remains without redness, swelling, or leakage. Which documentation actions are appropriate? Select all that apply.
1. Document the pump malfunction and interruption of the infusion in the clinical note.
2. Document the replacement pump’s operation, but keep the malfunction details only in the safety report.
3. Document the infusion restart, settings verification, and follow-up findings in the clinical note.
4. Write “See incident report for details” in the chart to avoid duplicating the event information.
5. Complete the safety report through the facility’s designated process, separately from the clinical note.
Answer: Document the pump malfunction and interruption of the infusion in the clinical note., Document the infusion restart, settings verification, and follow-up findings in the clinical note., Complete the safety report through the facility’s designated process, separately from the clinical note.
The clinical note needs to stand on its own by describing the equipment problem, interrupted therapy, actions, and follow-up. A separate safety report is still required; keeping malfunction details only there or referring the reader to it leaves the clinical account incomplete.
At 1415, you are documenting repositioning scheduled for 1400. A second staff member was unavailable, so you notified the charge RN and requested assistance at 1402. At 1415, you repositioned the patient onto the left side with RN assistance, offloaded the heels, and found sacral skin intact without erythema. Which approach best documents this in the patient’s chart?
1. Chart the repositioning under its scheduled time of 1400, including the care provided and skin findings; explain the later completion in the staffing-objection record.
2. Chart the scheduled and actual care times, unavailable second staff member, notification and assistance request, care provided, and skin findings.
3. Chart the care provided at 1415 and the skin findings; document the reason for the delay and the assistance request only in the staffing-objection record.
4. Chart “Repositioning delayed due to short staffing; management aware,” followed by the actual care time, care provided, and skin findings.
Answer: Chart the scheduled and actual care times, unavailable second staff member, notification and assistance request, care provided, and skin findings.
The patient’s chart should connect the specific barrier and delay with the request for help, actual care, and assessment findings. Putting the barrier and request only in the staffing-objection record leaves the clinical account incomplete, while using the scheduled time makes late care appear on time. “Short staffing; management aware” is less useful because it omits the specific missing support and traceable notification.
At 0820, you are completing a staffing-objection follow-up. At 0730, you telephoned the nursing supervisor about your assignment concern and requested additional RN coverage; the supervisor said a float RN was expected at 0800. At 0810, the float RN had not arrived, and you contacted the supervisor again. At 0820, the float RN arrived and assumed care of two patients after handoff, leaving you with four patients. Which documentation choices accurately capture the follow-up? Select all that apply.
1. Record the 0730 telephone notification, assignment concern, request for additional RN coverage, and supervisor’s statement that a float RN was expected at 0800.
2. Record that the float RN had not arrived at 0810 and that you contacted the supervisor again at that time.
3. Record 0800 as the start of additional RN coverage because that was the arrival time communicated by the supervisor.
4. Use only the 0820 arrival and final four-patient assignment as the follow-up, omitting the earlier expected arrival and repeat contact because coverage was ultimately provided.
5. Record the float RN’s actual arrival at 0820, assumption of care for two patients after handoff, and your revised four-patient assignment.
Answer: Record the 0730 telephone notification, assignment concern, request for additional RN coverage, and supervisor’s statement that a float RN was expected at 0800., Record that the float RN had not arrived at 0810 and that you contacted the supervisor again at that time., Record the float RN’s actual arrival at 0820, assumption of care for two patients after handoff, and your revised four-patient assignment.
The follow-up should preserve the timed sequence of the request, supervisor’s response, repeat contact, and assistance that actually arrived. An expected arrival at 0800 does not establish that coverage began then. Recording only the final assignment loses the delay and escalation that explain how the concern was addressed.
At 09:00 in the PACU, a patient reports pain of 8/10 while resting quietly without crying. Which entry best documents this assessment?
1. Patient reports pain 8/10; resting quietly without crying.
2. Pain severity unconfirmed because observed behavior does not match the reported 8/10.
3. Mild postoperative pain; patient remains quiet despite reporting 8/10.
4. Patient reports pain 8/10; score considered unreliable because the patient appears comfortable.
Answer: Patient reports pain 8/10; resting quietly without crying.
The correct entry preserves the patient's subjective pain report while separately describing observed behavior. The other entries downgrade, withhold acceptance of, or discredit the reported severity because the patient is quiet, although outward expression does not determine pain intensity.
At 11:00, you have documented a postoperative patient's pain score as 6/10. The record lists a prescribed analgesic but does not describe the pain or the patient's response to treatment. Which actions should you take to complete the baseline pain assessment documentation? Select all that apply.
1. Ask the patient where the pain is located and how it feels, then record the responses.
2. Identify the surgical incision as the pain location based on the procedure performed.
3. List the prescribed analgesic as an alleviating factor based on the medication order.
4. Ask whether movement or position changes worsen the pain, then document the response.
5. Ask what helps relieve the pain, then document the factors the patient identifies.
Answer: Ask the patient where the pain is located and how it feels, then record the responses., Ask whether movement or position changes worsen the pain, then document the response., Ask what helps relieve the pain, then document the factors the patient identifies.
The baseline assessment should establish the patient's pain location, quality, and aggravating or alleviating factors. The surgical procedure alone does not establish where the patient actually hurts, and an analgesic order alone does not establish that the medication has relieved the pain.
At 15:00, a hospitalized postoperative patient requests heat/cold therapy for pain. There is no provider order for this modality. Which plan should you document?
1. Use heat/cold therapy under the patient's existing order for postoperative analgesic medication.
2. Offer heat/cold therapy as a comfort measure, then request an order if the patient reports benefit.
3. Obtain a provider's order before applying heat/cold therapy.
4. Begin heat/cold therapy at the patient's request and notify the provider at the next update.
Answer: Obtain a provider's order before applying heat/cold therapy.
The section requires a provider's order before applying these nonpharmacological modalities in the hospital. A patient's request or an analgesic medication order does not satisfy that requirement, and obtaining an order or notifying the provider afterward reverses the required sequence.
At 0900, a nurse reviews an elevated PSA result after the provider documented prostate enlargement on digital rectal examination. Further diagnostic testing is pending. Which entry best reflects the available findings?
1. Prostate enlargement and elevated PSA indicate BPH rather than prostate cancer.
2. Prostate enlargement and elevated PSA noted; findings may indicate either BPH or prostate cancer.
3. Prostate enlargement and elevated PSA indicate a urinary tract infection associated with BPH.
4. Prostate enlargement and elevated PSA establish prostate cancer; further testing will determine its extent.
Answer: Prostate enlargement and elevated PSA noted; findings may indicate either BPH or prostate cancer.
An elevated PSA can indicate either BPH or prostate cancer, so the entry should preserve that uncertainty. Prostate enlargement does not establish BPH rather than cancer, and elevated PSA does not confirm cancer. These findings also do not establish a urinary tract infection.
At 1600, a patient with BPH reports frequent nighttime urination and asks whether drinking less would help. Which instructions should the nurse include in the documented teaching plan? Select all that apply.
1. Reduce fluid intake as much as possible throughout the day to minimize urine production.
2. Avoid excessive fluid intake during the four hours before bedtime.
3. Keep evening fluid intake unchanged and rely on scheduled voiding alone to address nighttime frequency.
4. Drink enough fluids to maintain adequate hydration.
5. Use caffeinated drinks before bedtime so their diuretic effect helps empty the bladder.
Answer: Avoid excessive fluid intake during the four hours before bedtime., Drink enough fluids to maintain adequate hydration.
The section recommends balancing adequate hydration with avoiding excessive fluid intake, especially within four hours of bedtime. Reducing intake as much as possible does not preserve that balance, and scheduled voiding does not replace the fluid-intake recommendations. Caffeine is something to limit, not use as a bedtime bladder-emptying strategy.
At 1400, a patient receiving continuous bladder irrigation after TURP has pink-tinged urine with no clots, and the catheter is draining. Which evaluation should the nurse document based on these observations?
1. Pink-tinged urine without clots; the desired response has not been achieved because the urine is not clear.
2. Pink-tinged urine without clots; urine appearance is consistent with the ideal response to continuous bladder irrigation.
3. Pink-tinged urine without clots; the irrigation rate needs to be increased to eliminate the remaining discoloration.
4. Pink-tinged urine without clots; urine appearance establishes that irrigation is ready for discontinuation.
Answer: Pink-tinged urine without clots; urine appearance is consistent with the ideal response to continuous bladder irrigation.
The section identifies pink-tinged urine with few to no clots as the ideal response to continuous bladder irrigation. Clear urine is not the stated target, and the observations do not support increasing irrigation solely to eliminate the pink color. The section also does not establish these findings as criteria for discontinuing irrigation.
At 1400, a nurse assessing a patient with a lower-leg fracture finds diminished distal pulses, swelling with taut skin, numbness, and difficulty moving the extremity. Which assessment-and-plan entry best reflects these findings?
1. Possible compartment syndrome; notify the treating provider immediately.
2. Possible compartment syndrome; repeat the neurovascular assessment at the next scheduled check before contacting the provider.
3. Possible fat embolism; focus reassessment on neurological changes and shortness of breath.
4. Expected fracture-related swelling; continue pain-control and comfort measures.
Answer: Possible compartment syndrome; notify the treating provider immediately.
These findings match the section's warning signs of compartment syndrome, which require immediate provider notification. Waiting for another assessment or treating the findings as expected swelling delays the required response; fat embolism does not best explain this cluster of local extremity findings.
At 0900, a nurse assesses an external fixation device and finds no redness or drainage at the pin sites. The nurse is updating the routine pin-care plan. Which entries are supported by the section? Select all that apply.
1. Defer routine cleansing while the pin sites remain free of redness and drainage.
2. Clean the pin sites daily with soap and water.
3. Gently rub the pin sites dry after washing.
4. Dab the pin sites dry after washing.
5. Increase the interval between cleanings as fracture pain improves.
Answer: Clean the pin sites daily with soap and water., Dab the pin sites dry after washing.
The section specifies daily cleaning with soap and water followed by dabbing dry. Rubbing can cause friction and skin breakdown. Neither the absence of infection signs nor improvement in fracture pain supports deferring or reducing daily pin-site cleaning.
At 1100, after a patient's lower-leg cast is removed, the nurse notes decreased swelling, improved pain, normal skin color, a strong distal pulse, and the ability to move the toes. A follow-up x-ray has not yet been performed. Which evaluation entry is best supported?
1. Remaining pain indicates unsuccessful treatment; another cast is required.
2. Reduced pain and swelling confirm complete bone healing; treatment is complete.
3. Assessment findings support treatment effectiveness; follow-up x-ray is needed only if pain or swelling increases.
4. Assessment findings support treatment effectiveness; follow-up x-ray will evaluate fracture healing and whether further treatment is needed.
Answer: Assessment findings support treatment effectiveness; follow-up x-ray will evaluate fracture healing and whether further treatment is needed.
The observed improvements are signs of effective treatment, and the section also calls for a follow-up x-ray to assess healing and the need for further treatment. These findings do not independently confirm complete healing, remaining pain alone does not establish treatment failure, and the section does not make follow-up imaging conditional on worsening symptoms.
At 0900, a patient with osteoarthritis reports that joint pain makes personal care difficult and says, "I want to keep doing things for myself." Which care-plan entry best addresses this concern?
1. Emphasize ROM exercises and regular physical activity to support joint movement.
2. Provide emotional support as the patient adjusts to needing assistance with personal care.
3. Focus on pain relief with prescribed analgesics and heat or cold application before personal care.
4. Support participation in as many ADLs as possible and consult occupational therapy about adaptive devices.
Answer: Support participation in as many ADLs as possible and consult occupational therapy about adaptive devices.
Supporting participation in ADLs and exploring adaptive devices directly addresses the patient's goal of maintaining independence. Pain management, exercise, and emotional support are appropriate components of care, but those entries do not explicitly plan how the patient will continue performing personal care.
At 1400, a patient with osteoarthritis reports taking NSAIDs more often because joint pain persists. Which entry should the nurse include in the education plan to address the medication-safety concern?
1. Explain that OA symptoms can be managed even though joint damage cannot be reversed.
2. Discuss physical activity and ROM exercises as additional approaches to managing OA.
3. Review how NSAIDs relieve mild to moderate joint pain and reduce inflammation.
4. Explain the link between NSAID overuse and increased gastrointestinal bleeding risk.
Answer: Explain the link between NSAID overuse and increased gastrointestinal bleeding risk.
The section specifically links NSAID overuse to increased gastrointestinal bleeding risk and directs nurses to educate patients about this adverse effect. The other entries describe relevant OA teaching, but they do not address the safety risk raised by taking NSAIDs more often.
At 1900, a nurse is documenting an end-of-shift evaluation for a patient receiving OA pain medication and comfort measures. Which reassessment entries support documenting that the current plan of care is effective? Select all that apply.
1. Patient reports that the knee continues to give out intermittently.
2. Patient reports less joint pain than at the beginning of the shift.
3. Affected joint has increased range of motion compared with the earlier assessment.
4. Affected joint has less swelling than on the earlier assessment.
5. Patient reports that stiffness after prolonged sitting remains unchanged.
Answer: Patient reports less joint pain than at the beginning of the shift., Affected joint has increased range of motion compared with the earlier assessment., Affected joint has less swelling than on the earlier assessment.
Pain relief, decreased swelling, and increased ROM are outcomes the section identifies as evidence that the patient is improving. Unchanged stiffness and continuing knee instability are OA manifestations, but these entries do not demonstrate improvement in response to care.
At a 1000 survivorship visit, a patient reports persistent fatigue and asks what might improve energy. The nurse is documenting a teaching plan. Which entry is best supported by the section?
1. Discuss exercise as the intervention consistently shown to reduce fatigue and improve overall energy.
2. Discuss acupuncture as the intervention consistently shown to reduce fatigue and improve overall energy.
3. Discuss nutritional changes as the intervention consistently shown to reduce fatigue and improve overall energy.
4. Discuss massage as the intervention consistently shown to reduce fatigue and improve overall energy.
Answer: Discuss exercise as the intervention consistently shown to reduce fatigue and improve overall energy.
The section identifies exercise as the only intervention consistently shown to reduce fatigue and improve energy. Massage and acupuncture are described as options for symptoms such as pain or nausea, while nutrition is a general health-promotion topic rather than the intervention identified for this outcome.
At 1430, a patient who has completed cancer treatment and is in remission asks what ongoing care will involve. The nurse is updating the survivorship teaching plan. Which entries belong in that plan? Select all that apply.
1. Reinforce medication adherence and side-effect management.
2. Teach that new symptoms, rather than scheduled surveillance, will determine when diagnostic testing is needed.
3. Review the purpose of scheduled follow-up appointments.
4. Explain diagnostic testing used to monitor ongoing remission or detect recurrence.
5. Omit side-effect teaching from the survivorship plan because cancer treatment has ended.
Answer: Reinforce medication adherence and side-effect management., Review the purpose of scheduled follow-up appointments., Explain diagnostic testing used to monitor ongoing remission or detect recurrence.
The section identifies follow-up appointments, surveillance testing, medication adherence, and side-effect management as ongoing teaching priorities. Relying only on new symptoms replaces the described surveillance approach, and completing treatment does not eliminate the need for side-effect teaching.
At 1530, a patient newly diagnosed with cervical cancer says she has not completed her family planning and asks about delaying treatment to pursue fertility preservation. No decision about treatment timing has been made. Which entry best documents the nurse's plan?
1. Coordinate discussion with oncology and fertility specialists about fertility preservation and the risks and benefits of delaying treatment.
2. Plan to postpone cancer treatment while fertility preservation is arranged, based on the patient's expressed interest.
3. Plan fertility counseling after cancer treatment is completed; focus current teaching on cancer-treatment needs.
4. Refer for counseling about family-planning distress; defer discussion of fertility-preservation options.
Answer: Coordinate discussion with oncology and fertility specialists about fertility preservation and the risks and benefits of delaying treatment.
The section calls for coordination among nurses, oncologists, and fertility specialists when patients consider delaying treatment for fertility preservation. That approach supports weighing fertility goals alongside cancer-treatment needs rather than documenting a delay as already decided. Postponing fertility counseling or addressing distress alone leaves the patient's request for guidance about preservation options unaddressed.
At 0900, you assess a heel wound with dry, adherent eschar and no cracking, redness, or other signs of infection. Which assessment-and-plan entry best reflects these findings?
1. Dry, adherent heel eschar without redness; soften with autolytic debridement to remove the necrotic barrier.
2. Dry, stable heel eschar without cracking or redness; retain intact as a natural covering.
3. Dry, adherent heel eschar without infection; debridement is indicated because the tissue is nonviable.
4. Dry, adherent heel scab without cracking; covering represents coagulated blood or exudate.
Answer: Dry, stable heel eschar without cracking or redness; retain intact as a natural covering.
Stable, intact heel eschar should remain in place because it serves as a natural barrier to infection. The debridement entries overlook this exception to removing nonviable tissue, while the scab entry incorrectly equates eschar with coagulated blood or exudate.
At 1000, you are documenting the rationale for an autolytic debridement plan for a noninfected wound with dry necrotic tissue. Which product-and-purpose statements are appropriate for this plan? Select all that apply.
1. Medicinal honey to donate moisture and support autolytic debridement.
2. Collagenase ointment to provide debridement through the body's intrinsic enzymes.
3. Hydrocolloid dressing as the preferred autolytic dressing for dry necrotic tissue.
4. Foam dressing as the preferred autolytic dressing for dry necrotic tissue.
5. Hydrogel to donate moisture and support autolytic debridement.
Answer: Medicinal honey to donate moisture and support autolytic debridement., Hydrogel to donate moisture and support autolytic debridement.
Hydrogels and medicinal honey donate the moisture needed to support autolytic debridement of dry necrotic tissue. The section recommends foam or hydrocolloid dressings when tissue is already moist. Collagenase is an exogenous enzyme used for enzymatic debridement, not the body's intrinsic autolytic mechanism.
At 1400, you review a wound plan that proposes autolytic debridement. The wound requires an immediate and significant decrease in necrotic tissue. Which assessment-and-plan entry best matches the section?
1. Autolytic debridement appropriate because it is highly selective and affects only necrotic tissue.
2. Continue autolytic debridement; reassess only after the necrotic tissue has fully separated.
3. Autolytic debridement takes several days to work; consider a different debridement modality.
4. Autolytic debridement appropriate because it is the most conservative type of debridement.
Answer: Autolytic debridement takes several days to work; consider a different debridement modality.
The section describes autolysis as a slow process that takes several days, and states that when a wound requires an immediate and significant decrease in necrotic tissue, a different modality should be considered. Being selective and conservative are true features of autolytic debridement, but they do not address the need for speed, and waiting for full separation delays the removal the wound needs.
At the 1200 assessment, the centimeter mark on a patient's NG tube reads 55 cm at the nare, matching the documented 0800 reading. Which entry best documents this external-position assessment?
1. 1200: NG tube external length unchanged from 0800.
2. 1200: NG tube mark at nare 55 cm, unchanged from 0800.
3. 1200: NG tube centimeter mark verified against previous documentation.
4. 1200: NG tube assessed; no change in external position noted.
Answer: 1200: NG tube mark at nare 55 cm, unchanged from 0800.
The section specifically requires documenting and verifying the centimeter mark at each assessment. The other entries describe an assessment or an unchanged position but omit the actual centimeter mark.
At 0800, an EN prescription replaces yesterday's prescription. It specifies a new formula and the same route and administration method, but omits the feeding rate and free water flush instructions. Before administering feeding, which entries appropriately document your prescription review and planned follow-up? Select all that apply.
1. Missing prescription components referred to the dietitian for authorization rather than to the provider.
2. Feeding rate unspecified; verify with provider before administering tube feeding.
3. Yesterday's feeding rate carried forward because the route and administration method are unchanged.
4. Free water flush amount and frequency unspecified; verify with provider before administering tube feeding.
5. Yesterday's flush amount and frequency carried forward because the new prescription does not specify changes.
Answer: Feeding rate unspecified; verify with provider before administering tube feeding., Free water flush amount and frequency unspecified; verify with provider before administering tube feeding.
The nurse should review the feeding rate and the amount and frequency of free water flushes, verifying concerns with the provider before feeding. Carrying forward previous instructions substitutes an assumption for verification. The dietitian assesses nutritional needs, but the section assigns prescribing and clarification of prescription concerns to the provider.
At 0930, a provider has inserted a central line for TPN. The chest x-ray has been obtained but has not yet been read, and the prescribed TPN is ready. Which entry best documents the appropriate administration status and plan?
1. 0930: Chest x-ray interpretation pending; TPN not started. Await confirmation of line position and absence of pneumothorax.
2. 0930: Chest x-ray interpretation pending; TPN started at a reduced rate until placement is confirmed.
3. 0930: Central line insertion completed by provider; TPN started, with chest x-ray review to follow.
4. 0930: Chest x-ray obtained; TPN started at the prescribed rate while interpretation is pending.
Answer: 0930: Chest x-ray interpretation pending; TPN not started. Await confirmation of line position and absence of pneumothorax.
The section requires the chest x-ray to be read before the central line is used, confirming position and absence of pneumothorax. Obtaining the image or completing line insertion does not satisfy that requirement. Starting at a reduced rate also bypasses the required confirmation and conflicts with following the prescribed TPN rate strictly.
At 1410, a patient with pneumothorax develops low blood pressure, cyanosis, and tracheal deviation. While the team prepares to intervene, which entry best documents the immediate care priority?
1. Suspected tension pneumothorax; preparing for immediate needle decompression without waiting for imaging.
2. Suspected tension pneumothorax; awaiting blood gas results to determine whether decompression is indicated.
3. Suspected tension pneumothorax; preparing for chest x-ray before proceeding with decompression.
4. Suspected tension pneumothorax; monitoring the response to oxygen before preparing for decompression.
Answer: Suspected tension pneumothorax; preparing for immediate needle decompression without waiting for imaging.
The section associates these findings with tension pneumothorax and identifies immediate needle decompression as its treatment. Waiting for imaging, a response to oxygen, or blood gas results would delay the required emergency intervention.
At 1900, you are documenting the response to treatment for a patient with pneumothorax and a chest tube. Which information most directly supports your evaluation of the patient's oxygenation and respiratory status over the shift? Select all that apply.
1. Integrity of the dressing at the chest tube insertion site.
2. Security of the connection between the chest tube and drainage device.
3. Changes in the patient's oxygen requirement.
4. Lung sounds on reassessment compared with earlier findings.
5. Pulse oximetry readings over the shift.
Answer: Changes in the patient's oxygen requirement., Lung sounds on reassessment compared with earlier findings., Pulse oximetry readings over the shift.
The section specifically identifies pulse oximetry, oxygen requirement, and lung sounds as measures to monitor when evaluating respiratory improvement. Dressing integrity and secure tubing connections are important chest-tube care observations, but they do not directly demonstrate improvement in oxygenation or respiratory findings.
At 1000, shortly after a chest tube is connected to treat a pneumothorax, you observe bubbles in the drainage device's water-seal/air-leak monitor. Which note best interprets this observation?
1. Bubbles observed in the water-seal/air-leak monitor, indicating a need to increase the prescribed suction.
2. Bubbles observed in the water-seal/air-leak monitor, consistent with expected air movement through the drainage system.
3. Bubbles observed in the water-seal/air-leak monitor, indicating a break in the drainage system.
4. Bubbles observed in the water-seal/air-leak monitor, confirming that adequate wall suction is applied.
Answer: Bubbles observed in the water-seal/air-leak monitor, consistent with expected air movement through the drainage system.
Bubbles are expected in this area as air from a pneumothorax moves through the drainage system; the section describes bubbles as unexpected when the device is evacuating fluid. Adequate wall suction is assessed using the bellows, not bubbling, and the observation does not establish a need to increase prescribed suction.
At 1400, a hospitalized patient reports painful urination and foul-smelling vaginal discharge. The nurse is documenting the assessment and planned next action. Which entry is most appropriate?
1. Symptoms attributed to chlamydia; plan to request treatment without further diagnostic testing.
2. Findings consistent with a UTI; plan to limit further evaluation to urinary infection.
3. Symptoms suggest a possible STI; plan to notify the care team and request further testing and treatment as needed.
4. Possible STI symptoms identified; plan to defer evaluation to outpatient follow-up because most STIs are treated there.
Answer: Symptoms suggest a possible STI; plan to notify the care team and request further testing and treatment as needed.
In the hospital, suspected STI findings should prompt care-team notification and a request for appropriate testing and treatment. These symptoms can resemble a UTI, so limiting evaluation to urinary infection or attributing them specifically to chlamydia is not supported by the findings alone. The availability of outpatient treatment does not justify postponing evaluation during hospitalization.
At a 1600 follow-up after STI treatment, a patient reports improved but persistent symptoms, distress about STI-related stigma, and uncertainty about prevention and where to obtain further care. Which entries appropriately reflect the nursing evaluation? Select all that apply.
1. Symptoms have improved but remain present; continue evaluating for resolution or progression.
2. Patient has unanswered prevention questions and needs help identifying resources; further education and resource identification are needed.
3. Prevention education complete because the patient has received medical treatment.
4. Patient reports stigma-related distress; psychological care needs further evaluation.
5. Treatment successful; infection eradicated based on the patient's report of symptom improvement.
Answer: Symptoms have improved but remain present; continue evaluating for resolution or progression., Patient has unanswered prevention questions and needs help identifying resources; further education and resource identification are needed., Patient reports stigma-related distress; psychological care needs further evaluation.
STI evaluation includes physical and psychological care, patient education, and resource identification. Persistent symptoms, stigma-related distress, and unanswered questions support documenting ongoing needs in these areas. Symptom improvement alone does not establish eradication, and receiving medical treatment does not demonstrate that education is complete.
At a 1000 follow-up visit, a patient with diagnosed HSV reports that the sores have healed and says, "That means the infection is gone." The nurse provides follow-up teaching. Which entry appropriately documents the teaching needed?
1. Explained that the infection can be considered resolved once sores and flu-like symptoms are absent.
2. Explained that HSV is lifelong and that periods without sores do not mean the infection has ended.
3. Explained that an antibody test is needed to determine whether healing eliminated HSV.
4. Explained that a swab of a future sore is needed before determining whether HSV persists between outbreaks.
Answer: Explained that HSV is lifelong and that periods without sores do not mean the infection has ended.
HSV is lifelong, so a period without sores does not establish that the infection has ended. Antibody testing indicates previous exposure, not whether healing eliminated HSV. A sore swab can help establish an uncertain diagnosis, but a future swab is not needed before teaching a patient with diagnosed HSV about its lifelong nature.
At a 10:00 follow-up visit, a nurse reviews a patient’s established stage 3 HIV diagnosis. The patient’s CD4 count has increased to 500 cells/µL with therapy. Which entry best reflects the section’s guidance on staging?
1. Stage 3 (AIDS); CD4 count has increased to 500 cells/µL with therapy.
2. HIV stage undetermined; repeat CD4 testing needed before retaining the previous stage.
3. Stage 1 (acute HIV); reclassified because the current CD4 count is 500 cells/µL.
4. Stage 2 (chronic HIV); reclassified because immune function has improved with treatment.
Answer: Stage 3 (AIDS); CD4 count has increased to 500 cells/µL with therapy.
The section states that an increased CD4 count with therapy does not move a patient back to an earlier stage. Reclassification as stage 1 or 2 incorrectly reverses staging, while documenting an undetermined stage disregards the established stage 3 diagnosis.
During a 09:00 care conference, a patient with HIV reports difficulty paying for care and uncertainty about housing. The nurse is organizing the interdisciplinary plan by team member. Which assessment items belong in the social-work portion of the documented plan? Select all that apply.
1. Potential interactions among the patient’s medications.
2. Availability of support from family or other people.
3. Stability of the patient’s housing.
4. Financial resources available to support care.
5. Dietary intake and nutritional status.
Answer: Availability of support from family or other people., Stability of the patient’s housing., Financial resources available to support care.
The section assigns assessment of financial resources, housing stability, and social support to social workers. Dietary intake and nutritional status belong to the nutritionist’s assessment, while medication-interaction monitoring is assigned to pharmacists and the medical team.
At 14:20, a nurse sustains a needlestick from a needle previously used on a patient and washes their hands. Which next action should the nurse take and then document?
1. Arrange blood testing for the source patient and report the incident when the results are available.
2. Take the first dose of antiretroviral postexposure prophylaxis and then report the incident.
3. Review the source patient’s HIV status and report the incident if HIV infection is confirmed.
4. Immediately report the incident to the facility’s infectious disease representative or as facility policy directs.
Answer: Immediately report the incident to the facility’s infectious disease representative or as facility policy directs.
The section directs immediate reporting after handwashing. Waiting for test results or confirmed HIV infection delays that response, while taking prophylaxis before reporting reverses the stated sequence. Source-patient testing when possible and prompt postexposure prophylaxis are additional measures, not replacements for immediate reporting.
At 09:00, a patient with suspected TB needs placement, but no negative airflow private room is available. Which entry best documents the interim infection-prevention plan?
1. Keep the patient wearing a surgical mask in the shared waiting area until a negative airflow room becomes available.
2. Move the patient away from others; patient masking is unnecessary when staff wear fit-tested respirators.
3. Move the patient away from others and have the patient wear a surgical mask during coughing episodes.
4. Keep a surgical mask on the patient and move the patient to a location away from others.
Answer: Keep a surgical mask on the patient and move the patient to a location away from others.
When a negative airflow room is unavailable, the section calls for both continuous patient masking and placement away from others. Remaining in a shared waiting area or masking only during coughing does not meet those instructions, and staff respirators do not replace patient masking.
At 14:00, a nurse uses teach-back after explaining how a patient receiving TB treatment can reduce transmission at home. Which statements should the nurse document as demonstrating understanding? Select all that apply.
1. I will isolate when possible and sleep alone.
2. I will cover my nose and mouth when I sneeze or cough.
3. I will avoid having visitors.
4. I can have visitors as long as their visits are brief.
5. I can share a bed again when my cough becomes less frequent.
Answer: I will isolate when possible and sleep alone., I will cover my nose and mouth when I sneeze or cough., I will avoid having visitors.
The section recommends isolating when possible, sleeping alone, avoiding visitors, and covering the nose and mouth during sneezing and coughing. Brief visits still conflict with avoiding visitors. Less frequent coughing is not identified as a reason to stop sleeping alone.
At a 10:00 follow-up after eight weeks of TB treatment, a patient reports an improved cough and asks whether treatment can end. Which entry best documents appropriate counseling?
1. Discussed stopping treatment once the cough resolves and restarting if symptoms return.
2. Explained that treatment can end after eight weeks because most bacteria have been eradicated.
3. Reviewed that treatment generally requires at least six months because persistent organisms can remain after the first eight weeks.
4. Explained that follow-up imaging showing improvement is sufficient to end treatment early.
Answer: Reviewed that treatment generally requires at least six months because persistent organisms can remain after the first eight weeks.
The section states that TB generally requires at least six months of treatment because organisms can persist beyond the first eight weeks. Eradication of most bacteria does not mean treatment is complete, and neither symptom resolution nor improved imaging is presented as sufficient justification for ending therapy early.
At 0900, a nurse is documenting how anemia affects oxygenation in a patient with decreased red blood cell volume. Which statement best connects this finding to its effect on oxygenation?
1. Unventilated alveoli leave fewer capillaries available for gas exchange.
2. Reduced hemoglobin limits the blood’s oxygen-carrying capability.
3. Restricted pulmonary blood flow decreases the lungs’ ability to oxygenate blood.
4. Narrowed airways limit airflow and reduce the oxygen available to the lungs.
Answer: Reduced hemoglobin limits the blood’s oxygen-carrying capability.
Decreased red blood cell volume reduces hemoglobin, limiting the blood’s ability to carry oxygen. Airway narrowing and unventilated alveoli describe different mechanisms associated with other conditions in the section. Restricted pulmonary blood flow describes a perfusion problem rather than the oxygen-carrying limitation identified here.
At 1400, a nurse explains how pulmonary blood flow responds when some alveoli are inadequately ventilated while others remain sufficiently ventilated. Which statements should the nurse include in the documented teaching summary? Select all that apply.
1. Pulmonary vessels widen in poorly ventilated areas to bring in more blood.
2. Capillary constriction reduces blood flow equally in poorly ventilated and sufficiently ventilated areas.
3. Blood flow remains unchanged until ventilation improves in the affected alveoli.
4. Capillaries in inadequately ventilated areas become constricted.
5. Blood flow is redirected toward sufficiently ventilated alveoli.
Answer: Capillaries in inadequately ventilated areas become constricted., Blood flow is redirected toward sufficiently ventilated alveoli.
The section describes capillary constriction in inadequately ventilated areas and diversion of blood toward sufficiently ventilated alveoli. Widening vessels in poorly ventilated areas reverses that response, while unchanged flow or an equal reduction across regions misses the redistribution described.
At 1900, a nurse reviews a draft entry: “Oxygenation confirmed by air moving into and out of the lungs.” The entry is based only on observed air movement. Which replacement accurately identifies what that observation establishes?
1. Air movement into and out of the lungs demonstrates ventilation.
2. Air movement into and out of the lungs confirms oxygen diffusion into the bloodstream.
3. Air movement into and out of the lungs demonstrates oxygen delivery to body tissues.
4. Air movement into and out of the lungs confirms blood flow through pulmonary capillaries.
Answer: Air movement into and out of the lungs demonstrates ventilation.
Movement of air into and out of the lungs establishes ventilation. Oxygenation involves oxygen entering the bloodstream, while pulmonary perfusion involves blood flowing through pulmonary capillaries. The other entries claim oxygen transfer, pulmonary blood flow, or tissue oxygen delivery that the stated observation does not establish.
At 07:55, immediately before surgery, you are participating in the team time-out and preparing its documentation. The planned procedure appears on both the operating room schedule and the consent form. Which action-and-entry pair matches the nurse's role described in the section?
1. Read the procedure from the operating room schedule; document that the procedure was verified.
2. Ask the surgeon to state the procedure from memory; document that the procedure was verified.
3. Read the procedure directly from the consent form; document that the procedure was verified.
4. Repeat the procedure reported during the preoperative handoff; document that the procedure was verified.
Answer: Read the procedure directly from the consent form; document that the procedure was verified.
The section specifically directs the nurse to read the procedure directly from the consent form during the time-out. The schedule, the surgeon's recollection, and the handoff do not replace that step, even if they name the same procedure.
At 10:30, surgery is still underway, and your initial positioning entry is already complete. You are reviewing entries describing ongoing positioning-safety care. Which entries reflect the practices described in the section? Select all that apply.
1. Neurovascular status monitored throughout surgery.
2. Initial positioning assessment used in place of ongoing monitoring while the patient's position remains unchanged.
3. Padding and support maintained throughout surgery.
4. Vital signs monitored throughout surgery.
5. Neurovascular monitoring reserved for recovery unless vital signs change.
Answer: Neurovascular status monitored throughout surgery., Padding and support maintained throughout surgery., Vital signs monitored throughout surgery.
The section calls for maintaining padding and support and monitoring both vital signs and neurovascular status throughout surgery. Deferring neurovascular monitoring or relying only on the initial positioning assessment does not meet that ongoing approach.
At 09:10, you review a draft positioning entry that says 'reverse Trendelenburg.' The patient is on their back with the head section of the bed raised, while the lower section remains horizontal; the table is not tilted head-up and feet-down. Which entry best matches the position you observe?
1. Reverse Trendelenburg position with the head up and feet down.
2. Fowler’s position with the head of the bed raised.
3. Orthopneic position with the patient leaning on an overbed table.
4. Supine position with no head elevation.
Answer: Fowler’s position with the head of the bed raised.
The observed position matches Fowler’s: the patient is supine with the head of the bed raised. Reverse Trendelenburg involves a head-up, feet-down position, the supine option omits the observed elevation, and orthopneic positioning requires sitting and leaning on an overbed table.
At 1900, a nurse reviews the shift's findings for a patient with thrombocytopenia. Vital signs have normalized, platelet counts have continued to decline, and clotting times are unchanged. Which end-of-shift entry documents the trends in all three measures the section says must be documented?
1. Vital signs normalized; overall response is improving, with platelet counts and clotting times to be reassessed.
2. Platelet counts declined; overall response is worsening, with vital signs and clotting times to be reassessed.
3. Vital signs normalized, but platelet counts continued to decline; clotting times remained unchanged.
4. Clotting times remained unchanged; overall response is stable, with vital signs and platelet counts to be reassessed.
Answer: Vital signs normalized, but platelet counts continued to decline; clotting times remained unchanged.
The section states that documentation is essential to visualize trends in vital signs, blood components, and clotting times. Only the correct entry records the trend of each measure. The other entries record one measure and defer the two findings that are already available. A single normalized measure also does not show improvement: the section lists normalized vital signs together with stabilizing or improving platelet levels and decreasing clotting times as indications of improvement.
At 1100, a nurse uses teach-back after discussing bleeding and injury prevention with a patient who has thrombocytopenia. Which patient statements support documenting an accurate understanding of the teaching? Select all that apply.
1. I only need to avoid alcohol when I notice bleeding.
2. I can participate in contact sports as long as I do not have visible bruises.
3. I will switch to an electric razor to help avoid cuts.
4. I can keep using a standard blade razor as long as I shave slowly.
5. I will use a soft toothbrush to help avoid injuring my gums.
Answer: I will switch to an electric razor to help avoid cuts., I will use a soft toothbrush to help avoid injuring my gums.
A soft toothbrush and an electric razor match the section's recommendations for reducing tissue injury and bleeding. Shaving slowly with a standard blade does not match the recommendation to avoid sharp objects. The section also advises avoiding contact sports and alcohol, rather than limiting those precautions to times when bruising or bleeding is visible.
At 1400, a nurse prepares a handoff note for a patient with confirmed heparin-induced thrombocytopenia (HIT). The platelet count has decreased, swelling is present, and no bleeding has been observed. Which entry best captures the condition-specific concern?
1. No bleeding observed despite the decreased platelet count; findings support improvement in HIT.
2. Platelet count decreased without observed bleeding; bleeding is the primary complication of concern from HIT.
3. Platelet count decreased with swelling; the lower count indicates reduced blood coagulability.
4. Platelet count decreased with swelling; thrombosis remains a concern despite no observed bleeding.
Answer: Platelet count decreased with swelling; thrombosis remains a concern despite no observed bleeding.
HIT combines a falling platelet count with increased blood coagulability, so the absence of bleeding does not remove the concern for thrombosis. The other entries misidentify the main HIT-related risk, infer reduced coagulability from the low count, or treat the absence of bleeding as evidence of improvement.
At 1800, a nurse reviews a draft note stating that an open wound is healing by secondary intention. The care plan specifies leaving the wound open until infection resolves, then closing it. Which replacement entry best reflects this plan?
1. Wound is healing by secondary intention because it is currently open.
2. Wound remains open pending infection resolution; delayed primary, or tertiary, closure is planned.
3. Wound is healing by primary intention because approximation of its edges is planned.
4. Wound is healing by secondary intention during infection treatment and will change to primary intention when closed.
Answer: Wound remains open pending infection resolution; delayed primary, or tertiary, closure is planned.
Planned delayed closure while infection resolves is tertiary intention, also called delayed primary intention. The first and fourth entries confuse an intentionally delayed closure with secondary intention, in which the wound heals from the bottom up because its edges cannot be approximated. The third entry describes primary intention before the edges have been brought together.
At 1000, a nurse documents excessive moisture and macerated edges in wound A, and an inadequately moist wound bed in wound B. Which assessment statements accurately connect these findings to barriers to healing? Select all that apply.
1. Maceration of wound A's edges suggests that additional moisture is needed.
2. Inadequate moisture in wound B may inhibit cellular activity.
3. The dry bed of wound B favors epithelialization by reducing moisture.
4. Maceration of wound A's edges may reflect excessive moisture.
5. Maceration of wound A's edges indicates that the wound edges are advancing.
Answer: Inadequate moisture in wound B may inhibit cellular activity., Maceration of wound A's edges may reflect excessive moisture.
Excessive moisture can macerate wound edges, while inadequate moisture can inhibit cellular activity. Drying the wound does not promote epithelialization; appropriate moisture supports the cellular migration needed for healing. Maceration is an edge problem requiring intervention, not evidence of edge advancement or a need for additional moisture.
At 1900, a nurse finds that a surgical incision's edges remain together, but the margins are red, drainage has increased since the morning assessment, and the patient reports increasing incisional pain. No separation is visible. Which entry most accurately communicates these findings?
1. Incision remains approximated despite redness, increased drainage, and increased pain; concern for dehiscence is deferred until separation is visible.
2. Partial dehiscence is present, as demonstrated by redness, increased drainage, and increased pain.
3. Incision remains approximated; redness, increased drainage, and increased pain are consistent with routine healing.
4. Incision remains approximated, with red margins, increased drainage, and increasing pain; findings raise concern for impending dehiscence.
Answer: Incision remains approximated, with red margins, increased drainage, and increasing pain; findings raise concern for impending dehiscence.
Redness around the margins, increasing drainage, and increasing pain are described as warning signs of impending dehiscence. Documenting actual dehiscence would overstate the findings because dehiscence means separation of the surgical wound's edges. Calling these changes routine or waiting for visible separation overlooks the warning signs already present.
At 0900, a patient with MS reports intermittent tingling and difficulty concentrating over the past several days. Neither symptom is present during the current assessment. Which entry best captures the findings for the nursing assessment note?
1. Reports intermittent tingling and difficulty concentrating over several days; findings indicate a current MS exacerbation.
2. Reports intermittent tingling and difficulty concentrating over several days; neither symptom is present at 0900.
3. No tingling or difficulty concentrating present during the 0900 assessment.
4. No symptoms present at 0900; details of tingling and concentration difficulties will be documented if they recur.
Answer: Reports intermittent tingling and difficulty concentrating over several days; neither symptom is present at 0900.
MS cues can appear intermittently, so the note should capture both the patient's reported symptoms and the current findings. The other entries omit relevant history, label a current exacerbation without sufficient support, or defer recording symptoms the patient has already reported.
At 08:15, during an ED patient's initial assessment, you identify limited support and uncertainty about resources at home. Testing is underway, and the disposition has not been decided. What is the best next step for the discharge plan?
1. Document the concerns and begin care coordination after the initial assessment, updating the plan as care continues.
2. Document the concerns and wait for a home-discharge decision before beginning care coordination.
3. Document the concerns for reassessment after testing is complete, then decide whether to begin care coordination.
4. Document the concerns in the transfer handoff so the next care setting can begin discharge coordination.
Answer: Document the concerns and begin care coordination after the initial assessment, updating the plan as care continues.
Care coordination should begin after the initial assessment and continue as an ongoing process. Waiting for a home-discharge decision, completed testing, or the next care setting delays addressing needs that have already been identified.
At 11:00, an ED patient with pneumonia is being transferred to the intensive care unit. You are organizing the written SBAR handoff. Which available information belongs in the Background section? Select all that apply.
1. Comorbidities relevant to the current situation.
2. Current assessment findings of bilateral coarse breath sounds.
3. Recommendations for future testing.
4. Previous treatments for the same condition.
5. Past surgeries relevant to the current situation.
Answer: Comorbidities relevant to the current situation., Previous treatments for the same condition., Past surgeries relevant to the current situation.
Background supplies history relevant to the current problem, including comorbidities, past surgeries, and treatments for the same condition. Current breath sounds belong in Assessment, while proposed future testing belongs in Recommendations.
At 16:30, a patient who received sedation is preparing to leave the ED with a companion. You are planning the aftercare review and its documentation. Which approach best follows the section?
1. Review aftercare activities with the companion and document that review in the discharge plan.
2. Review aftercare activities with the patient and document that a companion is available.
3. Review follow-up appointment details with the companion and document that the patient received aftercare instructions.
4. Give printed aftercare instructions to the companion and document receipt of the materials.
Answer: Review aftercare activities with the companion and document that review in the discharge plan.
For a patient who received sedation, the section specifically calls for reviewing aftercare activities with a companion. Reviewing only with the patient, recording receipt of printed materials, or discussing only follow-up appointments does not establish that the companion received the required aftercare review.
At the end of a postoperative shift, you evaluate Mr. Silva's care plan. His pain is well-managed, and his mobility is steadily improving toward the planned goals. Which entry best documents the evaluation and next step?
1. Pain and mobility have improved; terminate these portions of the plan because the recovery goals have been achieved.
2. Mobility goals are not yet fully achieved; revise the current interventions despite steady improvement.
3. Pain is well-managed and mobility is improving toward expected outcomes; continue the current interventions.
4. Planned pain management and mobility interventions completed; continue the plan because all scheduled care was delivered.
Answer: Pain is well-managed and mobility is improving toward expected outcomes; continue the current interventions.
Positive responses with goals progressively being met support continuing the current plan. Completing interventions alone does not establish effectiveness, and improvement does not establish that all goals have been achieved. Revision is appropriate when interventions are not fully effective or the patient's condition changes, not merely because recovery is still progressing.
At the end of the shift, you are documenting the evaluation of Mr. Silva's postoperative education. The planned teaching has been delivered, but you need evidence of its effectiveness. Which information should you document for that purpose? Select all that apply.
1. Completion of the planned postoperative teaching.
2. Mr. Silva's understanding of his medication schedule.
3. The inclusion of patient education in his care plan.
4. Mr. Silva's adherence to his postoperative exercise routine.
5. The medication and exercise topics covered during teaching.
Answer: Mr. Silva's understanding of his medication schedule., Mr. Silva's adherence to his postoperative exercise routine.
The section evaluates education through the patient's understanding of and adherence to postoperative instructions. Documenting his understanding of the medication schedule and adherence to exercises addresses those outcomes. The other entries document planned or delivered education, not whether it was effective.
At a subsequent checkup, Mr. Jacobs's cholesterol remains high despite a care plan focused on diet changes, increased physical activity, and regular monitoring. Which entry best connects the outcome evaluation to the next care-planning decision?
1. Cholesterol remains high; terminate the care plan because the initial interventions have not produced the expected result.
2. Lifestyle interventions have been implemented; document the goal as met because the planned care was delivered.
3. Cholesterol remains high, indicating the current approach has not achieved the expected outcome; revise the care plan.
4. Cholesterol remains high; continue the plan unchanged because regular monitoring is already included.
Answer: Cholesterol remains high, indicating the current approach has not achieved the expected outcome; revise the care plan.
Persistent high cholesterol indicates that the initial approach was not sufficiently effective, supporting revision based on the evaluation findings. Monitoring and completion of interventions do not demonstrate achievement of the patient outcome. Terminating the plan does not address the unmet need; the example instead describes adjusting the approach.
At 0900, a nurse notices a fluid-oozing rash on a patient's leg while gathering information for the assessment note. Which opening question best encourages the patient to describe the concern?
1. What can you tell me about the rash on your leg?
2. Have you noticed this rash before today?
3. Is the rash what concerns you most right now?
4. Have you already told your doctor about the rash?
Answer: What can you tell me about the rash on your leg?
An open-ended question invites the patient to describe the rash and provide details useful for a comprehensive assessment. The other questions may collect focused information, but they allow yes-or-no answers rather than encouraging a fuller account; asking whether the doctor was told may also make the patient feel judged.
At 1100, a nurse reviews communication notes from an assessment during which a patient said sharing personal health details was difficult. Which documented actions demonstrate active listening? Select all that apply.
1. Avoided asking for clarification so the patient would not have to revisit difficult details.
2. After the patient finished speaking, summarized the message and invited corrections.
3. Interrupted periodically to summarize details before allowing the patient to continue.
4. Acknowledged that sharing was difficult and invited the patient to say more.
5. Sat at the patient's level and turned toward the patient while listening.
Answer: After the patient finished speaking, summarized the message and invited corrections., Acknowledged that sharing was difficult and invited the patient to say more., Sat at the patient's level and turned toward the patient while listening.
Active listening involves focusing on the patient, acknowledging what they share, encouraging elaboration, and summarizing after they finish so they can correct misunderstandings. Interrupting disrupts the patient's account, while avoiding clarification can leave the nurse without a full understanding of the concern.
At 1500, during patient teaching, a patient says, "I don't understand those abbreviations." Before completing the teaching note, which communication approach should the nurse use?
1. Repeat the original explanation more slowly, pausing after each abbreviation.
2. Restate the information in plain language without confusing medical jargon or acronyms.
3. Provide a written copy of the same explanation so the patient can review the terminology independently.
4. Expand the abbreviations into their full medical terms and repeat the original explanation.
Answer: Restate the information in plain language without confusing medical jargon or acronyms.
Teaching must match the patient's health literacy, so the nurse should replace confusing jargon and acronyms with understandable language. Spelling out technical terms, providing the same wording in writing, or slowing the explanation does not by itself resolve language the patient cannot understand.
At 1400, a patient arrives in the emergency department with suspected poisoning. Toxicology results are pending. Before completing the initial nursing note, which communication action should the nurse take and document?
1. Notify Poison Control that the patient has suspected poisoning.
2. Include a request in the shift handoff for the next nurse to contact Poison Control.
3. Defer contacting Poison Control until toxicology results identify the substance.
4. Notify the health-care provider and contact Poison Control only if the patient's condition worsens.
Answer: Notify Poison Control that the patient has suspected poisoning.
The section requires Poison Control notification for suspected as well as confirmed poisoning, so pending results do not justify waiting. Waiting for deterioration or the next shift also delays the required notification; notifying the provider does not replace it.
At 0300, a nurse caring for a patient with a crush injury has assessed and documented distal skin color, pulses, and capillary refill. Which additional assessments should the nurse perform and document to complete the neurovascular check? Select all that apply.
1. Assess the patient's ability to move the affected extremity, if possible.
2. Review the patient's intake and output.
3. Review the patient's latest CPK level.
4. Assess what the patient feels when sensation is applied to the affected area.
5. Check the patient's urine for tea or dark red coloration.
Answer: Assess the patient's ability to move the affected extremity, if possible., Assess what the patient feels when sensation is applied to the affected area.
The documented findings address circulation; movement and sensation are the remaining components of the neurovascular assessment. Urine color, CPK, and intake/output are relevant to monitoring a patient with a crush injury, but they do not complete the missing neurovascular components.
At 1800, an ED nurse identifies unexplained bruising on a child and suspects abuse. While preparing the encounter note, the nurse considers the next step. Which action should the nurse take and then document?
1. Report the suspicion immediately through the appropriate state and health-care organization channels.
2. Record the bruising and wait for the caregiver to explain it before deciding whether to report.
3. Include the concern in the shift handoff and leave reporting to the receiving nurse.
4. Request a provider assessment and defer reporting until abuse is confirmed.
Answer: Report the suspicion immediately through the appropriate state and health-care organization channels.
The section directs nurses to report suspicions of abuse immediately through the proper channels; confirmation is not required before reporting. Waiting for a caregiver's explanation or provider confirmation delays that step, and mentioning the concern in handoff does not substitute for reporting.
At 19:15, a forensic nurse begins collecting evidence from a patient treated after an assault. The patient's clothing and injuries are available for assessment. Which documentation approach follows the section's required starting step?
1. Photograph the injuries and describe the patient and clothing in writing without photographing them.
2. Record the assault history and defer photographs until the chain of custody form is complete.
3. Document and photograph the patient, clothing, and injuries as evidence collection begins.
4. Collect and seal the evidence first, then document and photograph the patient, clothing, and injuries.
Answer: Document and photograph the patient, clothing, and injuries as evidence collection begins.
The section requires documentation and photographs of the patient, clothing, and injuries at the beginning of evidence collection. Sealing evidence or completing the chain of custody form first delays this required starting step. Photographing only injuries leaves out the required photographs of the patient and clothing.
At 20:40, a forensic nurse has sealed the collected clothing and specimens in individual evidence envelopes. Before proceeding to the chain of custody form, which labeling actions should the nurse complete? Select all that apply.
1. Use the chain of custody form as the only location for the nurse's signature.
2. Place the patient's information on each envelope.
3. Place the patient's information only on the clothing envelope because all specimens came from the same patient.
4. Sign each envelope.
5. Date and time each envelope.
Answer: Place the patient's information on each envelope., Sign each envelope., Date and time each envelope.
Each sealed item needs the patient's information, and each envelope must be signed, dated, and timed. Signing only another form or labeling only the clothing envelope does not meet these item-by-item requirements.
At 22:00, a nurse reviews the chain of custody form before releasing evidence to law enforcement. The collecting nurse is listed, but a second nurse who handled the sealed envelopes is missing. Which revision is appropriate?
1. Replace the collecting nurse's name with the second nurse's name to identify the most recent handler.
2. Add the second nurse only if that nurse opened an envelope or collected another specimen.
3. Keep only the collecting nurse's name because the envelopes remained sealed.
4. Add the second nurse and ensure the form identifies everyone who contacted the evidence until its release.
Answer: Add the second nurse and ensure the form identifies everyone who contacted the evidence until its release.
The chain of custody form identifies every person who has come into contact with the evidence until release to law enforcement. The section does not limit this to people who open envelopes or collect specimens, so omitting the second nurse or replacing the collector would leave the record incomplete.
Several hours after a patient with a positive COVID-19 test received ordered supplemental oxygen and IV fluids, the nurse reassesses the patient. Symptoms have improved, which was the expected outcome. Which entry best documents evaluation of outcomes using the CJMM?
1. Cough, fever, runny nose, shortness of breath, and dyspnea on exertion identified as relevant assessment cues.
2. Positive COVID-19 test supports the respiratory-virus hypothesis; provider notified and ordered care provided.
3. Symptoms improved following ordered interventions; observed response is consistent with the expected outcome.
4. Supplemental oxygen and IV fluids administered as ordered; patient reassessed several hours after treatment.
Answer: Symptoms improved following ordered interventions; observed response is consistent with the expected outcome.
The correct entry compares the patient's observed response with the expected outcome, demonstrating evaluation rather than simply recording completed tasks. The other entries document hypothesis confirmation, interventions and reassessment activity, or assessment cues without showing whether the expected outcome was achieved.
A patient with cough and fever has tested positive for COVID-19, and the provider has ordered supplemental oxygen and IV fluids. A nursing student has established priorities and a plan of care. Which activities belong to carrying out and documenting the CJMM's take-action step? Select all that apply.
1. Compare the patient's response to interventions with the expected outcomes.
2. Rank possible explanations for the patient's cough and fever by likelihood and seriousness.
3. Administer the ordered supplemental oxygen and IV fluids according to the established priorities.
4. Provide education to the patient and family.
5. Document the care provided to the patient.
Answer: Administer the ordered supplemental oxygen and IV fluids according to the established priorities., Provide education to the patient and family., Document the care provided to the patient.
Taking action includes performing interventions based on established priorities, documenting care appropriately, and educating the patient and family. Ranking possible explanations belongs to prioritizing hypotheses, while comparing observed and expected responses belongs to evaluating outcomes; both are useful but demonstrate different CJMM skills.
At the start of an assessment, a nurse is completing the dietary history for a patient from a culture in which vegetarian diets are common. The patient has not yet described their own diet. Which approach best supports individualized clinical judgment?
1. Ask about the patient's own dietary practices and document the specific information obtained.
2. Enter a vegetarian diet based on the patient's cultural background and ask the patient to confirm it during later teaching.
3. Use the culture's typical dietary pattern as a provisional cue unless the patient volunteers a different practice.
4. Document the cultural background but exclude dietary practices from the assessment to avoid stereotyping.
Answer: Ask about the patient's own dietary practices and document the specific information obtained.
Asking the patient provides specific information that can inform clinical decisions without treating a cultural pattern as an individual fact. Entering an assumed diet or relying on a typical pattern risks stereotyping, while excluding dietary practices discards potentially relevant context.
At 15:00, a disaster drill ends. The nurse preparing the debriefing summary observed effective team communication but difficulty locating supplies. Which entry best supports the purpose of the debriefing described in the section?
1. Communication was effective; supply-location difficulties need improvement; resource management should be a focus of further practice.
2. Drill completed; effective communication documented, with supply-location concerns reserved for the next staff feedback survey.
3. Drill completed with effective communication; overall response satisfactory despite difficulty locating supplies.
4. Supply-location difficulties were the main finding; the summary should focus on corrective actions rather than successful response elements.
Answer: Communication was effective; supply-location difficulties need improvement; resource management should be a focus of further practice.
The selected entry captures a strength, an area for improvement, and a lesson to guide further preparation. Reserving the problem for a survey or labeling the response satisfactory weakens the review of the observed difficulty. Focusing only on corrective actions leaves out strengths, which the section also identifies as part of debriefing.
At 09:00, a nurse helps revise the hospital's disaster plan to accommodate a larger-than-usual influx of patients. Which entries belong under the capacity-expansion procedures specifically described in the section? Select all that apply.
1. Describe assigning color-coded triage tags according to injury severity.
2. Outline procedures for opening additional patient care areas.
3. Outline procedures for mobilizing supplemental staffing.
4. Outline procedures for reallocating resources to meet increased demand.
5. Describe patient cohorting to minimize infectious disease transmission.
Answer: Outline procedures for opening additional patient care areas., Outline procedures for mobilizing supplemental staffing., Outline procedures for reallocating resources to meet increased demand.
The section identifies additional patient care areas, supplemental staffing, and resource reallocation as procedures in surge capacity plans. Triage tags support patient prioritization, while cohorting is listed under infection control; neither is one of the capacity-expansion procedures identified in this passage.
At 18:20, several green-tagged patients walk into the hospital after leaving the scene of a chemical incident. The nurse is preparing a handoff note. Which entry best highlights the arrival-related hazard emphasized in the section?
1. Green-tagged arrivals have nonurgent needs; their ability to wait for treatment is the key handoff concern.
2. Green-tagged arrivals may represent a large patient group; their contribution to patient volume is the key handoff concern.
3. Green-tagged arrivals from the chemical incident may carry contaminants into the hospital despite being able to walk.
4. Green-tagged arrivals reached the hospital independently; their ability to seek their own assistance is the key handoff concern.
Answer: Green-tagged arrivals from the chemical incident may carry contaminants into the hospital despite being able to walk.
The section specifically warns that green-tagged patients leaving an incident scene may carry contaminants into another environment. The other entries emphasize treatment priority, patient volume, or independent mobility, but none flags the contamination hazard associated with arrival from a chemical incident.
At 0900, a nurse reviews the facility's preparedness plan before an anticipated epidemic. Necessary supplies are listed, but outbreak-response protocols and staff training are not addressed. Which entry best addresses these preparation gaps?
1. Add patient screening and triage activities to be performed when affected individuals arrive.
2. Arrange interdisciplinary monitoring of disease transmission and identification of emerging hotspots.
3. Develop outbreak-response protocols and arrange staff training alongside the existing supply preparations.
4. Add community education about vaccination and hygiene practices to the existing supply preparations.
Answer: Develop outbreak-response protocols and arrange staff training alongside the existing supply preparations.
The section identifies supplies, protocols, and training as components of epidemic preparedness, so the entry should address the two missing components. The other activities are legitimate nursing responsibilities but do not resolve the identified protocol and training gaps.
At 1500, a nurse is documenting an infection-control plan for a patient suspected of having Ebola. The plan already includes gloves, a gown, an N95 respirator, and a face shield. Which addition best addresses prevention of transmission during this patient's care?
1. Perform handwashing and add isolation after Ebola is confirmed.
2. Arrange community health fairs and educational workshops about Ebola prevention.
3. Perform handwashing and isolate the patient while Ebola is suspected.
4. Collaborate with the interdisciplinary team to monitor transmission and identify emerging hotspots.
Answer: Perform handwashing and isolate the patient while Ebola is suspected.
The section specifically includes handwashing and isolation of suspected patients, making the third entry appropriate before confirmation. Waiting for confirmation does not follow that guidance, while community education and transmission monitoring do not replace the stated patient-level precautions.
At 0800, a nurse is assigned to a COVID-19 testing station rather than vaccination or direct treatment duties. Which tasks should the nurse include in the documented assignment plan based on the section's description of testing responsibilities? Select all that apply.
1. Conduct COVID-19 screenings.
2. Provide education on quarantine and isolation protocols.
3. Collect samples for COVID-19 testing.
4. Administer COVID-19 vaccines.
5. Manage symptoms and administer treatments to COVID-19 patients.
Answer: Conduct COVID-19 screenings., Provide education on quarantine and isolation protocols., Collect samples for COVID-19 testing.
The section groups screening, sample collection, and quarantine and isolation education within nurses' COVID-19 testing responsibilities. Vaccination and symptom management with treatment are also nursing roles, but they belong to duties excluded from this assignment.
During Mr. Hernandez's initial assessment for poorly controlled type 2 diabetes and recurrent foot ulcers, he reports being diligent with his medication, but his blood glucose readings are consistently high. Which entry best preserves the distinction between his report and the measured findings?
1. Patient reports being diligent with medication; blood glucose readings remain consistently high.
2. Patient likely misses medication doses, as indicated by consistently high blood glucose readings.
3. Patient's medication regimen is ineffective, as demonstrated by consistently high blood glucose readings.
4. Patient takes medication as prescribed; blood glucose readings remain consistently high.
Answer: Patient reports being diligent with medication; blood glucose readings remain consistently high.
The correct entry identifies medication diligence as the patient's report and high blood glucose as measured data. The alternatives turn his report into verified adherence or attribute the readings to missed doses or an ineffective regimen, neither of which these findings establish.
While assessing Mr. Silva three days after knee replacement surgery, you find that his incision is red and warm to the touch. You are documenting the findings and their implications for care. Which entries are supported by the assessment described in the section? Select all that apply.
1. Incision is red and warm to the touch three days after knee replacement surgery.
2. Incision changes will be evaluated further if additional symptoms develop.
3. Incision findings establish the presence of a postoperative wound infection.
4. Incision redness and warmth are consistent with expected healing at this postoperative stage.
5. Abnormal incision findings require further investigation and follow-up.
Answer: Incision is red and warm to the touch three days after knee replacement surgery., Abnormal incision findings require further investigation and follow-up.
The supported entries record the observed cues and recognize that they are abnormal findings requiring investigation and follow-up. Describing them as expected healing minimizes their significance, while documenting an established infection goes beyond the assessment. Waiting for additional symptoms makes follow-up conditional even though the existing findings already warrant it.
Before completing an assessment summary, you review a patient's blood pressure readings over several visits and recognize a pattern of increasing values. Which entry best documents your analysis of that pattern?
1. Blood pressure readings are increasing across visits; this pattern may indicate poorly controlled hypertension.
2. Increasing blood pressure readings across visits confirm that the patient's hypertension is poorly controlled.
3. Blood pressure readings are increasing across visits; interpretation will wait until the patient reports symptoms.
4. Individual blood pressure readings are documented; interpretation should focus on the latest reading rather than the pattern.
Answer: Blood pressure readings are increasing across visits; this pattern may indicate poorly controlled hypertension.
The rising pattern supports a possible interpretation of poorly controlled hypertension, not a definitive conclusion. Waiting for reported symptoms adds a condition the section does not require, while focusing only on the latest reading discards meaningful trend information.
At 1500, before hurricane season, a nurse reviews a draft community emergency plan. It identifies who will respond and how teams will communicate, but does not address moving residents to safety or distributing supplies. Which addition best addresses these gaps?
1. Outline infrastructure repairs and long-term housing assistance.
2. Add evacuation procedures and resource allocation strategies.
3. Specify land-use changes and building-code improvements.
4. Expand assigned responder roles and add communication contacts.
Answer: Add evacuation procedures and resource allocation strategies.
The missing preparedness elements are evacuation procedures and resource allocation strategies. Expanding roles and communication contacts repeats content already covered, while infrastructure repairs and housing assistance address recovery, and land-use or building-code changes address mitigation.
At a 0900 disaster-preparedness meeting, a nurse is updating an emergency shelter plan for a culturally diverse community. Which entries directly address cultural considerations in the plan? Select all that apply.
1. Arrange resource sharing with neighboring communities.
2. Translate emergency communications into multiple languages.
3. Conduct disaster drills with community members.
4. Respect cultural practices related to mourning and burial.
5. Accommodate dietary restrictions in emergency shelters.
Answer: Translate emergency communications into multiple languages., Respect cultural practices related to mourning and burial., Accommodate dietary restrictions in emergency shelters.
Multilingual communication, dietary accommodations, and respect for mourning and burial practices directly incorporate cultural needs into disaster planning. Drills and resource sharing support general preparedness, but those entries do not themselves address cultural differences.
At 1030 during a disaster response, several injured or ill residents arrive at an emergency medical shelter at the same time. Which entry should the nurse add to the intake plan to guide the order in which these residents receive care?
1. Organize vaccinations to help prevent the spread of illness.
2. Triage arriving patients according to the severity of their injuries or illnesses.
3. Coordinate with emergency responders to facilitate evacuation.
4. Assign intake nurses to monitor for infectious disease outbreaks.
Answer: Triage arriving patients according to the severity of their injuries or illnesses.
Severity-based triage provides the basis for prioritizing care among arriving patients. Disease surveillance, evacuation assistance, and vaccination are also nursing responsibilities in the section, but they do not specify how to determine these patients' order of care.
At 0900, a nurse reviews follow-up access with a patient who lives far from a specialist. The patient's insurance covers telehealth, but the patient reports having neither high-speed Wi-Fi nor the technology needed for a remote visit. Which note best describes the current access problem?
1. Telehealth coverage confirmed; remote follow-up can replace travel to the specialist.
2. Telehealth may reduce the travel barrier, but access to the necessary technology remains unresolved.
3. Distance limits specialist access; transportation assistance is the only remaining access need.
4. Telehealth is not an option for this patient; future follow-up must occur in person.
Answer: Telehealth may reduce the travel barrier, but access to the necessary technology remains unresolved.
Insurance coverage does not make telehealth practical when the patient lacks the necessary connection and technology. The first option assumes access is established, the third overlooks the technology barrier, and the fourth treats a current limitation as a permanent restriction.
At 1100, a nurse interviews a patient for a possible home care referral. The patient reports that leaving home requires major effort and that a walker is needed because of substantial illness. The patient also reports having a part-time job without health insurance benefits, limited bus routes, and no nearby specialist. Which findings should the nurse document specifically as support for the Medicare home care criteria described in the section? Select all that apply.
1. The patient lives far from an appropriate specialist.
2. The patient's part-time job does not provide health insurance benefits.
3. Available bus routes do not serve all needed destinations.
4. Leaving home requires major effort.
5. The patient needs a walker to leave home because of substantial illness.
Answer: Leaving home requires major effort., The patient needs a walker to leave home because of substantial illness.
The listed Medicare criteria include major effort to leave home and difficulty leaving without assistance because of substantial illness or injury. Employment-related insurance gaps, limited bus routes, and geographic distance are access barriers, but the section does not list them as Medicare home care eligibility criteria.
At 1500, a nurse updates the discharge plan for an older adult admitted after a fall. The patient previously lived alone, but the interdisciplinary evaluation has identified a need for a higher level of care. Resources have not yet been arranged. Which entry best reflects the next step described in the section?
1. Return to the previous living arrangement planned because the patient lived independently before admission.
2. Transfer to rehabilitation required because the patient experienced a fall while living alone.
3. Higher level of care identified; the interdisciplinary team will coordinate resources to support a safe discharge.
4. Discharge home planned; the appropriate level of care will be determined during the initial home care visit.
Answer: Higher level of care identified; the interdisciplinary team will coordinate resources to support a safe discharge.
After the required level of care is determined, the interdisciplinary team works to obtain the necessary resources for a safe discharge. Previous independent living does not override the current evaluation, and determining care needs should not be deferred until after discharge. A fall alone does not establish that rehabilitation is the required destination.
At 0900, a nurse is documenting a teaching plan for a patient with diabetes. The goal is for the patient to monitor blood glucose correctly. Which planned outcome best measures achievement of this goal?
1. By the end of today's teaching session, the patient will competently perform a blood glucose check as a return demonstration.
2. By the end of today's teaching session, the nurse will have completed blood glucose monitoring education.
3. By the end of today's teaching session, the patient will explain the complications of untreated diabetes.
4. By the end of today's teaching session, the patient will report confidence in checking blood glucose at home.
Answer: By the end of today's teaching session, the patient will competently perform a blood glucose check as a return demonstration.
A return demonstration directly shows whether the patient can perform the monitoring skill, and the deadline makes the outcome timed. Explaining complications or reporting confidence does not demonstrate the skill, while completing education measures the nurse's activity rather than the patient's competence.
At 1000, a nurse is documenting assessment findings for a patient with a chronic illness and identifying interprofessional follow-up needs. Which entries most directly support involving the social worker? Select all that apply.
1. The patient's financial resources for managing the chronic condition need review.
2. The patient's prescriptions need review to ensure correct medications and dosages.
3. The patient needs counseling and a dietary plan to support healthy eating habits.
4. The patient's access to community resources for managing the chronic condition needs review.
5. The patient needs support to improve performance of activities of daily living.
Answer: The patient's financial resources for managing the chronic condition need review., The patient's access to community resources for managing the chronic condition needs review.
Financial and community resources fall within the social worker's role. Dietary planning belongs to the dietitian, support for activities of daily living to physical and/or occupational therapy, and prescription and dosage coordination to the pharmacist.
At 1600, a nurse evaluates a patient with diabetes and documents that the goal of competent blood glucose self-monitoring has not been met. Which plan-of-care update best follows this finding?
1. Outcome not met; continue the existing plan and defer decisions about changes until the next scheduled evaluation.
2. Outcome not met; extend the goal deadline while retaining the current priorities and interventions.
3. Outcome not met; repeat the current teaching while keeping the established care plan unchanged.
4. Outcome not met; coordinate revisions with the interdisciplinary team to address the patient's unmet needs.
Answer: Outcome not met; coordinate revisions with the interdisciplinary team to address the patient's unmet needs.
Unmet outcomes call for coordinated care-plan revisions that address the patient's needs, often involving the interdisciplinary team again. Deferring changes, repeating unchanged teaching, or only extending the deadline does not establish how the plan will address the unmet outcome.
At 0900, a triage nurse suspects conjunctivitis after a patient reports a crusted, red right eye and no foreign object. A same-day telemedicine visit is proposed. The patient has a mobile phone, but internet access has not been discussed. Which next step should the nurse include in the triage plan?
1. Confirm access to a computer because a mobile phone is insufficient for the visit.
2. Arrange an in-person visit because eye redness requires a physical examination.
3. Verify internet access before completing the telemedicine arrangements.
4. Complete video-visit scheduling because having a mobile phone establishes readiness.
Answer: Verify internet access before completing the telemedicine arrangements.
The section's scheduling process includes confirming internet access as well as access to a mobile phone or computer; a phone alone does not establish both. It also presents suspected conjunctivitis as appropriate for telemedicine, so neither an automatic in-person visit nor a computer-only requirement is supported.
At 1000, while preparing a telemedicine consultation, a nurse receives a request from a family member to participate in the patient's health-care decisions. The patient has not yet expressed a preference about family involvement. Which plan should the nurse document?
1. Include the family member because the request indicates that family participation is important.
2. Ask whether the patient wants the family member involved and obtain the patient's consent before including them.
3. Allow the family member to join only the closing discussion based on the family's request.
4. Keep the consultation patient-only to maintain confidentiality during telemedicine.
Answer: Ask whether the patient wants the family member involved and obtain the patient's consent before including them.
The section supports family participation when the patient desires and consents to it. A family member's request does not establish patient consent, and limiting participation to the closing discussion does not resolve that gap. Automatically excluding family also overlooks the patient's preference.
At 1500, after teaching a patient about an AI-supported telemedicine service, the nurse is documenting the patient's understanding of AI's intended role. Which patient statements support accurate understanding? Select all that apply.
1. The chatbot's initial assessment can serve as my provider's final assessment.
2. Making care more efficient can give my provider more time to spend with me.
3. Once the AI learns enough patterns, it can provide the same wisdom and compassion as my provider.
4. The main goal is to reduce the time my provider spends interacting with me.
5. The AI should support my provider rather than take my provider's place.
Answer: Making care more efficient can give my provider more time to spend with me., The AI should support my provider rather than take my provider's place.
AI is intended to complement the provider and improve efficiency, allowing more time with patients. Its initial assessment does not replace the provider's role, and efficiency is not presented as a reason to reduce patient interaction. The section also identifies AI's inability to demonstrate wisdom or compassion.
At 06:45, a patient brings a walker to the preoperative unit. Before surgery, you place it in the preoperative storage room. Which documentation best supports postoperative staff in returning the patient's belongings?
1. Personal assistive device secured in the preoperative storage room before surgery.
2. Walker brought from home; to be returned to the patient after surgery.
3. Walker used for mobility; postoperative staff informed that the patient brought an assistive device.
4. Walker brought from home; placed in the preoperative storage room before surgery.
Answer: Walker brought from home; placed in the preoperative storage room before surgery.
The section directs the nurse to document both the type of assistive device and where it was placed so postoperative staff can return it. The other entries omit either the device type or its storage location.
At 09:00, a patient who does not read or understand English needs surgical consent and preoperative education. A family member offers to interpret. Which planned language accommodations should you include in the preoperative care documentation? Select all that apply.
1. Provide written materials in the language the patient reads and understands.
2. Arrange a medically trained interpreter for preoperative education.
3. Use the bilingual family member instead of a medically trained interpreter for preoperative teaching.
4. Arrange a medically trained interpreter for the consent discussion.
5. Provide the standard English-language packet with a summary from the family member.
Answer: Provide written materials in the language the patient reads and understands., Arrange a medically trained interpreter for preoperative education., Arrange a medically trained interpreter for the consent discussion.
The section requires a medically trained interpreter for both consent and education, along with materials in the language the patient reads and understands. Substituting a bilingual family member for the interpreter or using an English packet with a family summary does not meet those requirements.
At 07:30, an older adult says, "I feel warm enough," after you apply a warming blanket. You are updating the preoperative note. Which entry best reflects the section's approach to temperature safety?
1. Patient reports adequate warmth; comfort goal met and temperature monitoring complete.
2. Patient reports adequate warmth; further temperature checks planned only if the patient reports feeling cold.
3. Patient comfortable with warming blanket; temperature monitoring deferred while warming continues.
4. Patient reports adequate warmth with warming blanket; temperature monitoring will continue.
Answer: Patient reports adequate warmth with warming blanket; temperature monitoring will continue.
An older adult's report of feeling warm may not reflect actual body temperature, so monitoring must continue for safety. Waiting for discomfort, deferring checks during warming, or ending monitoring when comfort improves substitutes subjective comfort or the warming intervention for continued temperature assessment.
At the end of a morning visit, a nurse is preparing the self-management section of a care plan for a patient with hypertension. Which planned action best applies the Chronic Care Model's approach to helping the patient limit sodium intake?
1. Work with the patient to agree on a sodium-reduction goal and identify strategies for achieving it.
2. Select a sodium-reduction goal for the patient and explain the instructions for meeting it.
3. Provide sodium-reduction education and ask the patient to develop a goal and strategies independently.
4. Agree with the patient on a sodium-reduction goal and leave strategy development for the next visit.
Answer: Work with the patient to agree on a sodium-reduction goal and identify strategies for achieving it.
The model supports collaborative goal development and staff-assisted problem solving to help patients manage chronic disease. The other approaches provide education or establish a goal, but leave out either shared goal setting or current assistance with strategies for achieving it.
At 3:00 p.m., a nurse is updating the electronic care plan for a patient with a chronic illness who will continue care with another provider. Which planned actions directly use information sharing to support a smooth transition? Select all that apply.
1. Retrieve best-practice guidelines for the patient's chronic condition from a clinical database.
2. Make the patient's care-plan information available to the patient as part of coordinating ongoing care.
3. Generate a list of patients with the same chronic disease to monitor their health status over time.
4. Share the patient's current care-plan information with the provider who will continue care.
5. Review the care team's performance and patient outcomes for the previous month.
Answer: Make the patient's care-plan information available to the patient as part of coordinating ongoing care., Share the patient's current care-plan information with the provider who will continue care.
Sharing patient-specific information with both the patient and the continuing provider supports coordination and smooth transitions. Performance monitoring and disease-specific patient lists serve other clinical information system functions, while retrieving guidelines provides decision support; none of these actions alone shares the patient's care information for this transition.
At 2:00 p.m., a clinic nurse is drafting a care plan for a patient with a chronic condition the nurse rarely encounters. The nurse is unsure which management approach is supported by evidence. Which action best addresses that uncertainty before completing the plan?
1. Review the patient's recorded health-status trends to summarize progress over time.
2. Access condition-specific best-practice guidelines through a clinical system or database.
3. Review the patient's self-management goals to identify personal priorities.
4. Review the care team's assigned roles and the patient's scheduled follow-up contacts.
Answer: Access condition-specific best-practice guidelines through a clinical system or database.
Decision support makes evidence-based guidelines available when clinicians are unfamiliar with a condition or unsure how to manage it. Health-status trends, patient goals, and team responsibilities contribute to care planning, but they do not substitute for condition-specific evidence-based guidance.
At 1400, a patient is being discharged home. Your draft discharge summary describes the patient's condition and the care provided. Which addition best completes the summary to support continuity of care?
1. Add appointment information and instructions for accessing the patient portal.
2. Add recent diagnostic results and the provider's medical orders.
3. Add vital-sign trends and a summary of earlier assessments.
4. Add necessary education and home care instructions.
Answer: Add necessary education and home care instructions.
The section describes a discharge summary as covering the patient's condition, care provided, necessary education, and home care instructions. Diagnostic results, orders, and assessment trends may add clinical detail but do not fill the identified gaps. Appointment and portal information alone do not provide the necessary education and home care instructions.
At 1030, you are preparing documentation for a debrief after a patient fall. Event data from the patient's smart bed are available. Which entries would support an accurate reconstruction of the event? Select all that apply.
1. Document the bed's currently observed settings as the settings in effect during the fall.
2. Record which bed settings were activated according to the event data.
3. Estimate this alarm's duration using the unit's typical alarm-response time.
4. Describe how the patient moved before the fall according to the event data.
5. Record how long the bed alarm had been sounding according to the event data.
Answer: Record which bed settings were activated according to the event data., Describe how the patient moved before the fall according to the event data., Record how long the bed alarm had been sounding according to the event data.
The section identifies activated settings, alarm duration, and the patient's movements before a fall as useful smart-bed data for a debrief. Currently observed settings do not establish which settings were active during the event. A typical response time is an estimate, not the recorded duration of this patient's alarm.
At 0900, two clinics successfully exchange a patient's electronic record, but nurses interpret a diagnosis label differently because the clinics use different local terminology. Which documentation change most directly addresses this problem?
1. Arrange both clinics' records using the same section order and visual layout.
2. Use shared ICD-10 codes to represent diagnoses consistently across both clinics.
3. Apply stronger encryption and access controls to the exchanged records.
4. Transmit updated records more frequently between the clinics.
Answer: Use shared ICD-10 codes to represent diagnoses consistently across both clinics.
Terminology standards support shared meaning, and the section gives ICD-10 codes as an example for medical diagnoses. Consistent layouts address organization rather than conflicting terminology. Encryption protects information, and more frequent transmission improves timeliness, but neither resolves different interpretations of a diagnosis label.
At 1400, a nurse is completing a transition note for a patient going home with a caregiver and home-care services. Which entry best demonstrates the communication needed to support continuity of care?
1. Caregiver received the follow-up schedule and agreed to summarize the hospital stay at the first home-care visit.
2. Home-care services arranged; follow-up appointments scheduled; discharge documents finalized in the hospital record.
3. Patient and caregiver informed of planned services; home-care provider's contact information included in discharge paperwork.
4. Medical records, care plan, and discharge instructions communicated accurately to the home-care provider, patient, and caregiver.
Answer: Medical records, care plan, and discharge instructions communicated accurately to the home-care provider, patient, and caregiver.
The source calls for accurate communication of medical records, care plans, and instructions to home-care providers, caregivers, and the patient. Finalizing documents or providing contact information does not establish that this information reached the intended recipients. A caregiver's later summary and follow-up schedule do not demonstrate a complete discharge handoff.
At 1000, a nurse is updating the discharge teaching plan. The patient knows which pharmacy will fill the prescriptions but says, "I still do not understand my medication regimen." Which topics should the nurse include in the documented teaching plan to address this understanding gap? Select all that apply.
1. The prescribed dosage of each medication.
2. The arrangements for obtaining prescriptions from the community pharmacy.
3. How frequently each medication should be taken.
4. The potential side effects of the medications.
5. The scheduling of follow-up appointments with the care provider.
Answer: The prescribed dosage of each medication., How frequently each medication should be taken., The potential side effects of the medications.
The source specifically identifies dosages, frequency, and potential side effects as information patients need to understand about their medication regimen. Prescription arrangements and follow-up scheduling support discharge, but they do not address the medication-understanding gap described.
At a 0900 discharge-planning meeting, a nurse notices that the draft home-care plan records recommendations from nursing, physical therapy, and social work, but the patient's preferences and goals have not been discussed. Which revision should the nurse propose?
1. Discuss the patient's preferences, values, and goals, then document how they are considered in the care decisions.
2. Record the team's shared recovery goals now and plan to discuss the patient's preferences at the follow-up appointment.
3. Expand the record of each discipline's recommendations and use those recommendations as the basis for the final plan.
4. Ask the caregiver to identify preferred services and use those preferences to finalize the patient's plan.
Answer: Discuss the patient's preferences, values, and goals, then document how they are considered in the care decisions.
Collaborative care incorporates the patient's preferences, values, and goals when decisions are made. More detailed professional recommendations or postponing the discussion does not include the patient's input in the current plan. Caregiver participation can support planning, but it does not replace involving the patient.
At 4:00 p.m., an occupational health nurse reviews documentation from regular health checks of employees who work with potentially harmful chemicals. Which documentation approach best supports identifying changes in employees' health over time?
1. Maintain detailed employee medical histories and findings from regular health assessments.
2. Focus on first-aid encounters and injury claims, adding health information when employees need treatment.
3. Use workplace hazard assessments and safety-protocol updates as the main record for tracking employee health.
4. Use vaccination and N95-check records as the primary record of employees' ongoing health status.
Answer: Maintain detailed employee medical histories and findings from regular health assessments.
Detailed medical histories and regular assessments support tracking health trends and identifying areas of concern. Hazard assessments describe workplace risks, while first-aid encounters and claims focus on injury-related care. Vaccination and N95-check records address specific safety measures rather than the broader health monitoring described.
At 2:00 p.m., a school nurse reviews a draft individualized care plan for a student with diabetes. The draft contains the student's medical history but does not explain how the student's needs will be supported at school. Which additions should the nurse make? Select all that apply.
1. A standard diabetes information sheet designated as the student's complete care plan.
2. Communication strategies for coordinating support for the student.
3. Interventions addressing the student's specific medical needs.
4. Student-specific accommodations needed during the school day.
5. A note that communication arrangements will be discussed verbally when a problem occurs.
Answer: Communication strategies for coordinating support for the student., Interventions addressing the student's specific medical needs., Student-specific accommodations needed during the school day.
The section describes personalized care plans as outlining necessary accommodations, interventions, and communication strategies. A general information sheet does not provide an individualized plan, and deferring communication arrangements until a problem occurs leaves those strategies unspecified.
At 3:30 p.m., a school nurse finishes a student's vision and hearing screenings and reviews the student's vaccination information. While updating the student's health record, which approach best matches the recordkeeping described in the section?
1. Keep assessment findings and medical history current, recording only immunizations administered at school.
2. Keep immunization and screening records current, using the individualized care plan in place of the student's medical history.
3. Keep immunization information and medical history current, adding assessment findings only when a chronic condition is identified.
4. Keep immunization records, health assessment findings, and medical history accurate and current.
Answer: Keep immunization records, health assessment findings, and medical history accurate and current.
The section identifies immunization records, health assessments, and medical histories as components of accurate student health records. It does not limit assessment documentation to chronic conditions or immunization records to doses given at school. An individualized care plan outlines needed support; it does not replace the medical history.
At 09:00, you are documenting screening education for a patient whose family history places them at high risk for hyperlipidemia. Which entry best reflects the screening recommendation in this section?
1. Reviewed obtaining a lipid panel every 4–6 years.
2. Reviewed waiting until age 40 to begin regular lipid panels.
3. Reviewed obtaining a lipid panel more frequently, typically annually, because of increased risk.
4. Reviewed obtaining a lipid panel every other year because of increased risk.
Answer: Reviewed obtaining a lipid panel more frequently, typically annually, because of increased risk.
The section recommends more frequent, typically annual, lipid panels for individuals at high risk, including those with a family history. The 4–6-year interval applies to healthy adults; neither waiting until age 40 nor using an every-other-year schedule reflects its high-risk lipid screening guidance.
At the end of an admission interview, a medical interpreter confirms that Ms. Gonzalez wants her husband present for all care conversations. She had been quiet before he arrived but now appears more relaxed. Which communication plan should you document?
1. Use a medical interpreter and include the husband as the primary decision-maker.
2. Have a medical interpreter and the patient's husband available for care conversations and education.
3. Have the husband answer questions and interpret during future care conversations.
4. Use a medical interpreter for education, with the husband waiting outside to preserve privacy.
Answer: Have a medical interpreter and the patient's husband available for care conversations and education.
The interpreter confirmed the patient's preference, so the plan should preserve both interpreter support and her husband's presence. Having the husband interpret replaces the medical interpreter, while excluding him contradicts her stated preference. Wanting him present does not establish that he is the primary decision-maker.
At 1400, you are updating a patient's care plan before a discussion of confidential health information. Which entries appropriately address physical privacy during the discussion? Select all that apply.
1. Speak quietly at the bedside instead of adjusting the physical privacy setup.
2. Close the door or use dividing curtains as appropriate.
3. Reserve door or curtain closure for personal care rather than conversations.
4. Use the same privacy arrangement for every patient to maintain consistency.
5. Arrange adequate physical space for the confidential discussion.
Answer: Close the door or use dividing curtains as appropriate., Arrange adequate physical space for the confidential discussion.
The section calls for adequate physical space and privacy measures such as closing doors or using dividing curtains during confidential discussions. Speaking quietly alone, applying a uniform setup without considering individual needs, or reserving privacy measures for personal care does not meet the guidance described.
During a 0900 cultural assessment, a woman from South Asia reports not taking her medications because her husband does not believe in Western medicine and expects her to follow his wishes. Which entry best captures the social factor identified in this assessment?
1. Patient personally rejects Western medicine and therefore does not take prescribed medications.
2. Patient reports not taking medications because her husband opposes Western medicine and expects her to comply with his wishes.
3. Patient prefers traditional remedies instead of prescribed medications.
4. Patient is not taking medications because she needs additional education about their benefits.
Answer: Patient reports not taking medications because her husband opposes Western medicine and expects her to comply with his wishes.
The patient's report identifies family authority as a factor in medication-taking, which the section describes as part of social organization. The other entries assume a preference for traditional remedies, her own rejection of Western medicine, or an education deficit that the interview did not establish.
At 1000, you review documented changes in a patient's breathing rate and renal bicarbonate handling. Blood pH remains within 7.35 to 7.45. Which interpretation is most appropriate to include in the nursing assessment?
1. Blood pH is being maintained through respiratory regulation of bicarbonate and renal regulation of carbon dioxide.
2. The renal system is maintaining blood pH independently of the changes in breathing rate.
3. The normal blood pH indicates that ongoing adjustments to maintain acid–base balance are unnecessary.
4. The respiratory and renal changes are consistent with coordinated efforts to maintain blood pH.
Answer: The respiratory and renal changes are consistent with coordinated efforts to maintain blood pH.
The section describes respiratory and renal adjustments as interdependent mechanisms for maintaining normal blood pH. A normal pH does not mean those adjustments are unnecessary or that the kidneys act independently. The reversed-role entry is incorrect because the respiratory system regulates carbon dioxide, while the kidneys regulate bicarbonate.
At 1400, a patient with a seasonal viral illness reports recently losing a job, sleeping inadequately, and eating poorly. The patient previously recovered from a similar illness with few symptoms. Which interpretations are supported when documenting factors that may affect the current stress response? Select all that apply.
1. Inadequate sleep may leave the body less able to respond to the viral stressor.
2. The viral illness is the only relevant stressor because the current concern is physical.
3. Previous recovery with few symptoms indicates that the patient will respond similarly during this illness.
4. Poor nutrition may contribute to the body's difficulty responding to the viral stressor.
5. Recent job loss may add emotional stress to the physical stress of illness.
Answer: Inadequate sleep may leave the body less able to respond to the viral stressor., Poor nutrition may contribute to the body's difficulty responding to the viral stressor., Recent job loss may add emotional stress to the physical stress of illness.
Job loss, inadequate sleep, and poor nutrition can add burdens that make the body less able to respond to a virus. Previous recovery does not establish the current response because the person's circumstances have changed, and focusing only on the virus overlooks the additional stressors.
At 1900, a patient reports overusing alcohol to relieve emotional stress and describes resulting financial problems and conflict with others. Which assessment entry best captures the patient's adaptation?
1. Alcohol use is a positive adaptive behavior because the patient reports relief from emotional stress.
2. Alcohol use and the reported financial and social difficulties are separate issues rather than a coping-related pattern.
3. Alcohol use is a maladaptive coping behavior that provides stress relief while creating additional negative outcomes.
4. The patient's adaptation cannot be evaluated until alcohol use produces physical illness.
Answer: Alcohol use is a maladaptive coping behavior that provides stress relief while creating additional negative outcomes.
Short-term stress relief does not make a coping behavior positively adaptive when it also creates harm. The section specifically links alcohol overuse with social distress and financial problems, so these effects should not be treated as unrelated, and physical illness is not required to recognize the maladaptive pattern.
At 0915, a patient is preparing to ride an elevator. The patient says, "I know it is unlikely to crash," but reports a racing heart and is hyperventilating. Which assessment entry best reflects the section's explanation?
1. Racing heart and hyperventilation are consistent with sympathetic activation in response to a perceived threat.
2. Racing heart and hyperventilation reflect parasympathetic activation as the body attempts to restore balance.
3. Difficulty controlling breathing indicates exhaustion from prolonged stress rather than an immediate stress response.
4. Symptoms reflect recovery from the alarm stage because the patient can accurately describe the low risk.
Answer: Racing heart and hyperventilation are consistent with sympathetic activation in response to a perceived threat.
A perceived threat can trigger sympathetic activation even when the patient recognizes that the feared event is unlikely. That insight does not establish recovery, the immediate symptoms do not establish exhaustion, and the section associates this pattern with sympathetic, not parasympathetic, activation.
At 1000, a patient describes ongoing work stress and reports constipation and fatigue. The record also shows chronically elevated blood glucose. Which statements are supported for the nurse's assessment documentation? Select all that apply.
1. Persistent glucose elevation may be associated with prolonged activation of the stress response.
2. The elevated glucose is unrelated to ongoing stress because cortisol raises glucose only during brief threats.
3. Constipation may be associated with sustained sympathetic activation.
4. Ongoing stress may decrease immune effectiveness and increase susceptibility to infection.
5. Fatigue indicates that sympathetic activation has ended and the body's resources have been restored.
Answer: Persistent glucose elevation may be associated with prolonged activation of the stress response., Constipation may be associated with sustained sympathetic activation., Ongoing stress may decrease immune effectiveness and increase susceptibility to infection.
Prolonged sympathetic activation can contribute to constipation and chronic hyperglycemia, while long-term stress can weaken immune defenses. Cortisol's glucose-raising effects are not limited to brief threats; sustained release can contribute to chronic hyperglycemia. Fatigue can accompany prolonged activation and does not establish that the response has ended or resources have been restored.
At 1400, a nurse documents swelling confined to tissues around a wound. The assessment shows no change in blood glucose and no overall sympathetic response. Which interpretation should accompany these findings?
1. Stable systemic findings indicate resistance following an earlier generalized alarm response.
2. Unchanged blood glucose indicates that the swelling is unrelated to the body's physiological response to stress.
3. Findings establish an early systemic alarm response; generalized sympathetic changes are expected to follow the swelling.
4. Findings are consistent with local adaptation; a wound can produce a localized response without generalized sympathetic changes.
Answer: Findings are consistent with local adaptation; a wound can produce a localized response without generalized sympathetic changes.
The section describes a wound as a stressor that may produce only a local inflammatory response without systemic changes. Local swelling does not establish a systemic alarm or an earlier alarm-to-resistance sequence, and unchanged blood glucose does not rule out local adaptation.
At 1830, you provide music and dim the lights for a patient whose pain-relief goal is to rest comfortably. At 1900, the patient says, "I feel calmer, but I am still too uncomfortable to rest." Which documentation best evaluates the intervention?
1. Music and dimmed lighting provided; patient reports feeling calmer but remains too uncomfortable to rest. Goal of comfortable rest not met.
2. Music and dimmed lighting provided for comfort; patient tolerated both interventions.
3. Music and dimmed lighting provided; pain-relief goal met because the patient reports feeling calmer.
4. Patient reports feeling calmer after music and dimmed lighting; continue the current comfort plan.
Answer: Music and dimmed lighting provided; patient reports feeling calmer but remains too uncomfortable to rest. Goal of comfortable rest not met.
The correct entry documents the intervention and response, then evaluates that response against the patient's stated goal. Feeling calmer or tolerating an intervention does not establish goal attainment, and simply continuing the plan leaves the patient's remaining discomfort undocumented.
At 1430, a patient reports that guided imagery has not achieved the pain-relief goal documented in the care plan. You document this response. Which next steps are supported by the section? Select all that apply.
1. Consider additional therapies to add to the treatment plan.
2. Carry forward the initial response as the response to any added therapy.
3. Reassess after any added therapy and document the reassessment.
4. Document the response to an added therapy only if it differs from the initial response.
5. Document the added therapy when completed and reassess only if the patient requests more relief.
Answer: Consider additional therapies to add to the treatment plan., Reassess after any added therapy and document the reassessment.
When the patient's pain goal remains unmet, the section supports considering additional therapies, followed by reassessment and documentation. The initial response cannot substitute for assessing the added therapy, and reassessment and documentation are not limited to patient requests or changed findings.
At 1010, you finish a ten-minute heat application for chronic lower back pain. Your draft note includes the application times, use of a barrier between the heat source and skin, and the patient's report of reduced stiffness. Which additional assessment should you perform and document to address the heat-related injury risk identified in the section?
1. Determine whether the patient has reached the pain-relief goal in the care plan.
2. Ask whether the patient would prefer heat for future pain episodes.
3. Examine the application site for evidence of skin burns.
4. Assess whether the patient is now comfortable enough to rest.
Answer: Examine the application site for evidence of skin burns.
The section calls for routine examination of the treatment site for potential skin burns; documenting barrier use and symptom improvement does not replace that examination. Preferences, goal attainment, and ability to rest help evaluate treatment but do not assess the local skin injury risk from heat.
At 0800, a patient who can use the numerical rating scale reports pain of 8/10. You observe a neutral facial expression. Which entry best documents these findings?
1. Patient reports pain 8/10 on the numerical rating scale; facial expression neutral.
2. Pain rating deferred pending further observation because patient shows no facial signs of severe pain.
3. Patient reports pain 8/10; severity remains unconfirmed because facial expression does not support the rating.
4. Pain appears mild based on neutral facial expression; patient reports a rating of 8/10.
Answer: Patient reports pain 8/10 on the numerical rating scale; facial expression neutral.
The correct entry preserves both the patient's subjective pain rating and the observed facial expression without treating one as proof against the other. The other entries downgrade, question, or defer the patient's rating because of appearance, although the section explains that severe pain can occur with a neutral facial expression.
At 0930, your draft assessment note contains only 'Patient reports discomfort.' Before completing the note, you want a fuller description of the pain in the patient's own words. Which questions best support that goal? Select all that apply.
1. Is the pain mainly in your back?
2. What does the pain feel like?
3. What makes your pain worse?
4. How does the pain affect your daily activities and quality of life?
5. Would you describe the pain as aching?
Answer: What does the pain feel like?, What makes your pain worse?, How does the pain affect your daily activities and quality of life?
The selected questions invite the patient to describe pain characteristics, effects on daily life, and aggravating factors rather than simply confirm a suggestion. The two closed-ended questions limit the initial description to yes-or-no answers; the section recommends open-ended questions followed by clarification as needed.
At 1400, you complete a pain assessment, document an NRS rating of 7/10, and administer pain medication. At 1415, you reassess using the same scale, and the patient reports 4/10. Which entry best documents the reassessment and medication response?
1. 1400: Pain 7/10 on NRS; pain medication administered. Continue routine pain monitoring.
2. 1415: Pain medication effective; patient continues to have some discomfort.
3. 1415: Patient reports pain 4/10 on NRS, decreased from 7/10 before medication administered at 1400.
4. 1415: Pain medication ineffective because patient continues to report pain above 0/10.
Answer: 1415: Patient reports pain 4/10 on NRS, decreased from 7/10 before medication administered at 1400.
The correct entry records the reassessment time and the change in the patient's reported pain, providing specific evidence for evaluating effectiveness. The administration-only entry omits reassessment, while 'effective' with 'some discomfort' leaves out the measured response. Continued pain above zero does not by itself establish treatment failure; the section notes that a goal of zero may not be reasonable.
At 1000, a nurse follows up with a patient identified as being at risk for an STI. The patient received a prevention pamphlet but has not changed health-related behaviors. Which entry best describes the next teaching plan?
1. Record that prevention information was provided and reassess behavior changes at follow-up.
2. Review the patient's personal STI risk, consequences of infection, and safe sex practices in relation to the patient's lifestyle.
3. Provide another prevention pamphlet for the patient to review before the next visit.
4. Ask the patient to reread the pamphlet and bring questions to the next scheduled visit.
Answer: Review the patient's personal STI risk, consequences of infection, and safe sex practices in relation to the patient's lifestyle.
The section explains that pamphlets alone are ineffective and recommends explaining personal susceptibility, consequences, and safe sex practices. The other entries repeat written information, postpone additional teaching, or record information delivery without addressing the patient's need for individualized education.
At 1400, a patient asks to help choose wellness goals and review progress. The nurse is preparing the visit note. Which entries, if they accurately reflect the visit, demonstrate a person-centered partnership? Select all that apply.
1. Patient and nurse discussed possible approaches and agreed on the health-promotion plan.
2. Patient and nurse selected wellness goals that reflect the patient's personal values.
3. Patient and nurse agreed to evaluate progress together and discuss whether the plan meets the patient's goals.
4. Nurse finalized wellness goals based on the diagnosis and then explained the completed plan to the patient.
5. Nurse selected the evaluation criteria; patient was asked to follow the plan until the nurse's review.
Answer: Patient and nurse discussed possible approaches and agreed on the health-promotion plan., Patient and nurse selected wellness goals that reflect the patient's personal values., Patient and nurse agreed to evaluate progress together and discuss whether the plan meets the patient's goals.
A person-centered partnership involves patients in planning and evaluating care, with goals individualized to their values. Selecting goals together, agreeing on approaches, and jointly reviewing progress demonstrate that partnership; explaining a completed plan or assigning the patient only a follow-through role does not demonstrate shared decision-making.
At 1600, a nurse updates the health-promotion plan for a patient receiving medication-assisted treatment for addiction. The patient expects to return to the same social group and identifies that environment as a barrier to maintaining sobriety. Which planned-care entry best reflects a holistic approach?
1. Reinforce medication-assisted treatment and revisit relationship-building goals after cravings improve.
2. Focus the health-promotion plan on medication-assisted treatment and assessment of cravings.
3. Record the social barriers as background information while retaining the medication-focused plan.
4. Include social supports that encourage new relationships and strengthen confidence in behavioral change alongside medication-assisted treatment.
Answer: Include social supports that encourage new relationships and strengthen confidence in behavioral change alongside medication-assisted treatment.
The section describes a holistic approach that combines medication-assisted treatment, supportive relationships, and empowerment to make behavioral changes. Focusing on cravings or merely recording social barriers leaves the patient's environment unaddressed, while postponing relationship-building delays an identified component of the health-promotion plan.
At 1500, a nurse assesses an ankle injured earlier that day. The ankle is swollen, and movement is painful and limited. Which assessment entry best reflects these findings without adding an unsupported conclusion?
1. Permanent cellular damage evidenced by painful, limited ankle movement.
2. Local inflammation with swelling-related pain and reduced ankle function.
3. Systemic inflammatory response evidenced by ankle swelling and reduced mobility.
4. Ankle pain and swelling indicate muscle destruction related to the injury.
Answer: Local inflammation with swelling-related pain and reduced ankle function.
The section explains that tissue swelling can make movement painful and reduce function. The documented findings support this local effect but do not establish muscle destruction, systemic inflammation, or permanent cellular damage.
At 1700, a nurse reviews assessment findings for a patient with an infection. Which findings support documenting concern for a systemic inflammatory response rather than simply describing classic local signs of inflammation? Select all that apply.
1. Redness at the inflamed site
2. Tachycardia
3. Hypotension
4. Tachypnea
5. Pain at the inflamed site
Answer: Tachycardia, Hypotension, Tachypnea
The section identifies hypotension, tachycardia, and tachypnea among the features of systemic inflammatory response syndrome. Pain and redness are classic inflammatory signs, but their presence at the affected site does not by itself distinguish a systemic response from local inflammation.
At an 1800 assessment, a patient with chronic allergies reports constant itching eyes, a runny nose, skin inflammation, and emotional stress that have persisted for weeks. Which summary best captures the significance of this ongoing response?
1. Systemic inflammatory response, based on symptoms involving the eyes, nose, skin, and emotional well-being.
2. Acute protective response to seasonal allergens, without evidence of an ongoing inflammatory stressor.
3. Persistent allergy-related inflammation with physical and emotional stress and potential depletion of nutrients and energy.
4. Autoimmune hypersensitivity, based on the persistence of allergy symptoms.
Answer: Persistent allergy-related inflammation with physical and emotional stress and potential depletion of nutrients and energy.
The section links chronic allergies with lasting physical and emotional stress and explains that prolonged inflammation can become detrimental as nutrients and energy are depleted. Describing this persistent pattern only as an acute protective response misses its ongoing burden. Persistence alone does not establish autoimmune disease, and symptoms at several sites do not establish the systemic response described in the section.
At a 0900 follow-up, a patient who began an SSRI one week ago says, "My mood has not changed. Is it working?" Which teaching plan is most appropriate to document?
1. Explain that no improvement after one week indicates the medication is ineffective and another SSRI is needed.
2. Explain that the patient should evaluate effectiveness by looking for an immediate calming effect after each dose.
3. Explain that additional stress-management resources should wait until the medication's effectiveness is evaluated at 4–6 weeks.
4. Explain that reaching a therapeutic level may take 4–6 weeks and provide additional resources for managing stress.
Answer: Explain that reaching a therapeutic level may take 4–6 weeks and provide additional resources for managing stress.
The section explains that many antidepressants take 4–6 weeks to reach a therapeutic level and emphasizes providing additional stress-management resources. Declaring failure after one week or expecting immediate calming misrepresents that timeline. Delaying other resources overlooks the support patients need while waiting for a response.
You assessed a patient at 0730 on 09/08/2026 but did not enter the findings until 1015 that day. Which documentation approach best distinguishes when you assessed the patient from when you charted?
1. Use the approved workflow to retain the 1015 entry time and identify 0730 as the assessment time.
2. Label the note 'Late entry at 1015' without including the assessment time.
3. Display the assessment under 0730 and use that as the only visible time for the entry.
4. Use 1015 as the assessment time because that is when the findings became available in the chart.
Answer: Use the approved workflow to retain the 1015 entry time and identify 0730 as the assessment time.
The record should distinguish the 0730 assessment from the 1015 documentation. Showing only 0730 hides the documentation delay, using 1015 as the assessment time misdates the findings, and labeling a note 'Late entry' does not establish when the assessment occurred.
At 1800, you document events from earlier that day: nausea reported at 1540, Dr. Lee notified at 1545, ondansetron administered at 1555, and nausea denied on reassessment at 1620. Your draft groups everything under 1540. Which revisions accurately show the sequence? Select all that apply.
1. Document the notification to Dr. Lee at 1545 and ondansetron administration at 1555.
2. Document '1620: Patient denied nausea on reassessment.'
3. Keep '1540: Patient nauseated; MD aware; medication effective' as a single summary of the episode.
4. Write '1800: Patient denied nausea on reassessment' to match the note's entry time.
5. Keep 1800 as the entry time and identify 1540 as the time the patient reported nausea.
Answer: Document the notification to Dr. Lee at 1545 and ondansetron administration at 1555., Document '1620: Patient denied nausea on reassessment.', Keep 1800 as the entry time and identify 1540 as the time the patient reported nausea.
Keeping the entry time separate and assigning each event its actual time makes the sequence understandable. The single 1540 summary compresses separate events into one timestamp, while assigning 1800 to the reassessment makes an earlier finding appear current.
At 1705, you document that lunch was offered and the patient declined at approximately 1400 that day. You do not know the exact minute. How should you represent the timing?
1. Retain 1705 as the entry time and identify the event time as approximately 1400.
2. Write 'Patient declined lunch earlier' under the 1705 entry time without estimating the event time.
3. Use 1705 as the event time because it is the only exact time you can confirm.
4. Record 1400 as the exact event time because it is your best estimate.
Answer: Retain 1705 as the entry time and identify the event time as approximately 1400.
The event time should remain explicitly approximate, while 1705 identifies when you documented it. Recording 1400 as exact invents precision, using 1705 as the event time changes the chronology, and 'earlier' provides no usable point in the timeline.
At 1900 handoff, a CBC is ordered for 2000, but the specimen has not been collected. A. Patel, RN, confirms responsibility for collection and result follow-up. Which entry best makes this unfinished work actionable?
1. 1900: CBC ordered for 2000; specimen not yet collected. A. Patel, RN, confirmed collection and result follow-up during handoff.
2. 1900: A. Patel, RN, confirmed CBC follow-up. See orders for timing and laboratory record for collection status.
3. 1900: CBC ordered for 2000; specimen not yet collected. Result follow-up needed next shift.
4. 1900: Labs pending for 2000. A. Patel, RN, aware.
Answer: 1900: CBC ordered for 2000; specimen not yet collected. A. Patel, RN, confirmed collection and result follow-up during handoff.
The correct entry identifies the test's current stage, its due time, and the nurse who confirmed collection and result follow-up. The other entries leave the stage vague, omit confirmed responsibility, or require the receiving nurse to search elsewhere for essential handoff details.
You are preparing the 1900 handoff. The patient developed dizziness when standing at 1745 and denied dizziness at rest at 1845. The 1755 event note contains the assessment, provider communication, and interventions; assisted ambulation remains in the current care plan. Which entry best connects the earlier change with the current picture without copying the detailed note?
1. 1745: Dizziness when standing. See 1755 event note for assessment, provider communication, and interventions.
2. 1845: Denies dizziness at rest. Assisted ambulation remains in the care plan. See 1755 event note.
3. 1745: Dizziness when standing. At 1845, denies dizziness at rest. Assisted ambulation remains in the current care plan. See 1755 event note for assessment, provider communication, and interventions.
4. 1845: Denies dizziness at rest. Assisted ambulation remains in the care plan. See chart for earlier events.
Answer: 1745: Dizziness when standing. At 1845, denies dizziness at rest. Assisted ambulation remains in the current care plan. See 1755 event note for assessment, provider communication, and interventions.
The correct entry connects the timed change, current symptom status, and ongoing assistance needs, then names the detailed note and explains why it matters. The other entries use a vague destination, omit the current picture, or fail to identify the earlier change that makes the referenced note important.
You miss the 1900 shift-end report but complete a telephone handoff with A. Patel, RN, at 1915 through the approved channel. You also discover that earlier clinical information needs to be added to the record. Which documentation actions are appropriate? Select all that apply.
1. Record the handoff at 1900 to match the scheduled shift change, identifying A. Patel, RN, as the recipient.
2. Document that the telephone handoff with A. Patel, RN, actually occurred at 1915.
3. Follow the facility's late-entry process when adding the earlier clinical information.
4. Document only 'Report given to nights' at 1915, relying on the staffing assignment to identify the recipient.
5. Add the earlier clinical information to the handoff entry instead of following the facility's late-entry process.
Answer: Document that the telephone handoff with A. Patel, RN, actually occurred at 1915., Follow the facility's late-entry process when adding the earlier clinical information.
The handoff must reflect when the exchange actually occurred, and earlier clinical information should be added through the facility's late-entry process. Using the scheduled report time misrepresents the exchange, while placing earlier information in the handoff does not replace the late-entry process. 'Report given to nights' also fails to identify the actual recipient and method.
At 0800, the patient's left grip is weaker than the right, matching the documented admission assessment. Which entry best distinguishes the current abnormal finding from a normal assessment?
1. 0800: Neuro WNL; no change from admission.
2. 0800: Grip strength unchanged from admission assessment.
3. 0800: Left grip weaker than right, unchanged from documented admission assessment.
4. 0800: Left grip weaker than right.
Answer: 0800: Left grip weaker than right, unchanged from documented admission assessment.
The correct entry identifies both the current abnormal finding and the documented comparison point. 'WNL' can mislabel an unchanged abnormal finding as normal, while 'unchanged' alone hides the finding and the finding alone omits the baseline comparison.
At 0910, you review your documentation after a patient developed dyspnea while transferring to a chair. You returned the patient to bed, elevated the head of the bed, notified NP Rivera, started oxygen per a new order, and completed a reassessment. Your draft says, 'Respiratory WDL except shortness of breath. Provider aware.' Which revisions are appropriate if these details are not already recorded elsewhere? Select all that apply.
1. Use 'Continue to monitor' as the response portion of the entry.
2. Add the time dyspnea occurred, the respiratory findings, and the change from the earlier assessment.
3. Add the timed reassessment, including measured values, oxygen support, and the patient's symptoms after intervention.
4. Replace the draft with 'Respiratory status better after oxygen; provider aware.'
5. Add when NP Rivera was notified, what findings were reported, the new order, and the actions taken with their times.
Answer: Add the time dyspnea occurred, the respiratory findings, and the change from the earlier assessment., Add the timed reassessment, including measured values, oxygen support, and the patient's symptoms after intervention., Add when NP Rivera was notified, what findings were reported, the new order, and the actions taken with their times.
The record needs a timed connection between changed findings, actions, communication, and reassessment. 'Better' and 'provider aware' leave out the specific notification and response details. 'Continue to monitor' states an intention rather than documenting the reassessment already performed.
At 1400, you inspect a lower abdominal dressing. It is intact with a 3 × 2 cm area of serosanguineous drainage, unchanged from 1200; you cannot see the incision beneath it. Which entry most accurately communicates both your findings and the limits of this assessment?
1. 1400: Lower abdominal dressing intact; 3 × 2 cm serosanguineous drainage unchanged from 1200.
2. 1400: Lower abdominal dressing intact with 3 × 2 cm area of serosanguineous drainage, unchanged from 1200. Incision not visualized beneath dressing.
3. 1400: Lower abdominal surgical site WNL; dressing drainage unchanged from 1200.
4. 1400: Lower abdominal incision unchanged from 1200; dressing intact with 3 × 2 cm serosanguineous drainage.
Answer: 1400: Lower abdominal dressing intact with 3 × 2 cm area of serosanguineous drainage, unchanged from 1200. Incision not visualized beneath dressing.
The correct entry records the dressing findings and explicitly states that the incision was not visualized. A normal surgical-site label or an 'unchanged incision' statement claims more than you assessed, while the dressing-only entry leaves the assessment limitation unstated.
At 1200, you complete a focused reassessment of orientation, speech, hand grips, and bilateral ankle dorsiflexion. The findings match your 0800 assessment: alert and oriented to person, place, time, and situation; clear speech; equal grips and ankle dorsiflexion. Which entry best documents the reassessment without overstating its scope?
1. 1200: Alert; oriented to person, place, time, and situation. Speech clear. Hand grips and bilateral ankle dorsiflexion equal. These findings are unchanged from my 0800 assessment.
2. 1200: Neurological assessment unchanged from 0800.
3. 1200: Complete neurological examination normal; no change since 0800.
4. 1200: See 0800 neurological assessment for findings.
Answer: 1200: Alert; oriented to person, place, time, and situation. Speech clear. Hand grips and bilateral ankle dorsiflexion equal. These findings are unchanged from my 0800 assessment.
The correct entry records the current findings and identifies the assessment time used for comparison. 'Neurological assessment unchanged' leaves the findings and scope unclear, while 'complete neurological examination normal' claims more than this focused reassessment supports. Referring readers to the 0800 entry does not show what you actually assessed at 1200.
At 1000, you measure 250 mL of clear yellow urine that the patient voided into a urinal. The prior RN’s entry documents Foley removal at 0630, but your unsigned copied assessment still describes Foley drainage. Which statements belong in your revised entry? Select all that apply.
1. 1000: Voided 250 mL clear yellow urine into urinal.
2. 1000: Urinary assessment unchanged from prior RN’s entry.
3. 1000: Foley draining clear yellow urine; output 250 mL.
4. Foley removal at 0630 documented in prior RN’s entry.
5. 1000: Foley removed; voided 250 mL clear yellow urine.
Answer: 1000: Voided 250 mL clear yellow urine into urinal., Foley removal at 0630 documented in prior RN’s entry.
The selected statements distinguish the void you measured from Foley removal documented by another nurse. The Foley-drainage statement describes a device no longer present, while placing removal under 1000 obscures its actual time and source. 'Urinary assessment unchanged' does not document the measured void or make the scope of your assessment clear.
At 0900, the patient declines sacral skin inspection because of fatigue. You explain the purpose of the inspection, but the patient continues to decline. Your copied assessment says, 'Skin intact. No redness or breakdown.' Which replacement best documents what happened?
1. 0900: Patient declined sacral skin inspection, reporting fatigue. Explained purpose of inspection; patient continued to decline. Sacral skin not assessed at this time.
2. 0900: Sacral skin not assessed at this time.
3. 0900: Patient reports fatigue; skin assessment unchanged.
4. 0900: Skin intact; sacral inspection deferred because of fatigue.
Answer: 0900: Patient declined sacral skin inspection, reporting fatigue. Explained purpose of inspection; patient continued to decline. Sacral skin not assessed at this time.
The correct entry identifies the unassessed area, explains why it was not assessed, and records what actually happened. Calling the skin intact or unchanged implies findings you did not obtain. Documenting only 'sacral skin not assessed' avoids that implication but omits the reason.
At 1430, you are amending an admission note you signed at 1330. At 1420, the patient's daughter reported that the patient uses a walker for all ambulation at home. You have not observed the patient ambulate with a walker. Which wording best describes the added information?
1. Addendum to admission note signed at 1330: At 1420, the patient's daughter reported that the patient uses a walker for all ambulation at home. This information was not available when the admission note was signed.
2. Correction to admission note signed at 1330: The note should state that the patient ambulates with a walker, based on the daughter's 1420 report.
3. Late entry for 1330: Patient uses a walker for all ambulation at home.
4. Addendum: Patient ambulates with a walker. Admission history updated.
Answer: Addendum to admission note signed at 1330: At 1420, the patient's daughter reported that the patient uses a walker for all ambulation at home. This information was not available when the admission note was signed.
Information received after signing is added as an addendum that names the original note, attributes the information to the daughter, and gives the time it was received. A correction implies the original note stated something wrong, and a late entry documents earlier care you left out; neither fits information that arrived later. 'Patient ambulates with a walker' presents the daughter's report as your own finding, and 'history updated' does not say what was added.
At 0950, you discover that your note signed at 0910 incorrectly records a PRN dose as administered at 0900. The patient declined, and you did not administer it. You are preparing a correction stating these facts, but the medication administration record (MAR) still shows the dose as given, and another nurse could act on that. Which additional actions are appropriate? Select all that apply.
1. Promptly tell the nurse or clinician using this information that the documented dose was not administered.
2. Add 'no harm done' because the patient did not receive the medication.
3. Route the signed correction for routine review instead of contacting anyone directly.
4. Correct the MAR entry through that section's authorized correction process.
5. Leave the MAR entry unchanged, relying on the narrative correction to explain the discrepancy.
Answer: Promptly tell the nurse or clinician using this information that the documented dose was not administered., Correct the MAR entry through that section's authorized correction process.
Fixing the narrative does not fix the MAR, which is the field other nurses act on; it needs its own authorized correction, and the people using the information need to hear about a clinically relevant correction directly. Routine review does not replace that communication. 'No harm done' claims more than you assessed, and leaving the MAR unchanged keeps the wrong information in front of the next nurse.
At 1800 on 09/12/2026, you realize that your nursing note signed at 1615 omitted repositioning you performed earlier that day. You remember providing the care at approximately 1600, but you cannot verify the exact minute. Which timing statement belongs in your late entry?
1. Late entry entered at 1800 for care provided at 1615, the time the original note was signed.
2. Entry time set to 1600 so the note matches when the care was provided.
3. Late entry entered at 1800 for care provided at approximately 1600, omitted from nursing note signed at 1615; based on my recollection.
4. Late entry entered at 1800 for care provided at 1600; exact time established from my recollection.
Answer: Late entry entered at 1800 for care provided at approximately 1600, omitted from nursing note signed at 1615; based on my recollection.
The late entry keeps the actual entry time separate from the earlier care time, identifies the note it supplements, and keeps an approximate recollection approximate. Setting the entry time to 1600 backdates the entry, calling the time exact adds precision you do not have, and the original note's signature time does not show when the care happened.
At 0905, you review a preliminary urine culture report: >100,000 CFU/mL gram-negative rods; identification and susceptibilities pending. The patient reports burning with urination; temperature 37.1°C, HR 84. Which wording best preserves the meaning of the report and your assessment?
1. Temperature 37.1°C, HR 84; patient reports burning with urination. Urine culture documentation deferred until the final report is available.
2. UTI confirmed. Culture positive. Patient reports burning with urination.
3. Preliminary urine culture reports >100,000 CFU/mL gram-negative rods; identification and susceptibilities pending. Patient reports burning with urination; temperature 37.1°C, HR 84.
4. Urine culture positive for infection; final report pending. Temperature 37.1°C, HR 84.
Answer: Preliminary urine culture reports >100,000 CFU/mL gram-negative rods; identification and susceptibilities pending. Patient reports burning with urination; temperature 37.1°C, HR 84.
The correct entry keeps the laboratory's finding, its preliminary status, what is still pending, and your assessment as separate facts. 'UTI confirmed' and 'positive for infection' turn a preliminary finding into a diagnosis. Waiting for the final report leaves the current finding and its status out of the record.
At 1500, you review an outside urine culture fax reporting gram-negative rods without a preliminary or final status. At 1505, you call the reporting laboratory to clarify the status; a response is still pending. At 1510, you send Dr. Lee a secure message with the finding, missing status, and assessment, but have not received acknowledgment. Which communication entries accurately document what has happened? Select all that apply.
1. 1505: Reporting laboratory notified of missing report status; status clarification completed.
2. 1510: Secure message sent to Dr. Lee with reported finding, missing status, and assessment; acknowledgment pending.
3. 1510: Dr. Lee aware of gram-negative rods, missing report status, and current assessment.
4. 1505: Called reporting laboratory to clarify whether the report is preliminary or final; response pending.
5. 1510: Outside report reviewed by Dr. Lee; awaiting laboratory clarification.
Answer: 1510: Secure message sent to Dr. Lee with reported finding, missing status, and assessment; acknowledgment pending., 1505: Called reporting laboratory to clarify whether the report is preliminary or final; response pending.
The correct entries name whom you contacted, when, what you asked or sent, and that the response is still pending. Calling the laboratory does not mean the question is settled. Sending a message is not the same as getting acknowledgment, so 'Dr. Lee aware' or 'reviewed by Dr. Lee' claims something that has not happened.
At 1010, M. Green, MLS, calls a potassium result of 6.2 mmol/L, flagged critical, with a hemolysis comment. The patient denies palpitations; HR 88, BP 126/74. At 1012, you notify Dr. Lee by phone of the result, the specimen comment, and your assessment, and receive orders for a repeat potassium and an ECG. Neither has been done yet. Which entry best documents the situation at 1012?
1. 1012: Dr. Lee notified of critical potassium 6.2 mmol/L, hemolysis comment, and assessment; repeat specimen collected and ECG obtained per orders.
2. 1012: Potassium high because sample hemolyzed. Dr. Lee notified; repeat potassium and ECG ordered.
3. 1012: Potassium 6.2 mmol/L with hemolysis comment. Patient stable; no urgent concern. Repeat potassium and ECG ordered.
4. 1012: Dr. Lee notified by phone of critical potassium 6.2 mmol/L, hemolysis comment, and assessment. Repeat potassium and ECG ordered.
Answer: 1012: Dr. Lee notified by phone of critical potassium 6.2 mmol/L, hemolysis comment, and assessment. Repeat potassium and ECG ordered.
The correct entry records the notification and the orders without turning ordered work into completed work. The first option charts collection and the ECG before they happened. 'High because sample hemolyzed' presents a specimen comment as proof that the result is wrong, and 'patient stable; no urgent concern' replaces the assessment with a vague label and dismisses a critical result.
At 0930, A. Gomez, RRT, tells you that a nebulizer treatment was completed at 0920. At 0932, you assess the patient: RR 20/min, SpO₂ 95% on 2 L/min nasal cannula, speaking in full sentences. Which entry best distinguishes what was reported from what you assessed?
1. 0932: Nebulizer treatment completed at 0920. RR 20/min, SpO₂ 95% on 2 L/min nasal cannula; patient speaking in full sentences.
2. 0930: A. Gomez, RRT, reported nebulizer treatment completed at 0920. 0932: On my assessment, RR 20/min, SpO₂ 95% on 2 L/min nasal cannula; patient speaking in full sentences.
3. 0932: Per RT, nebulizer treatment completed at 0920; RR 20/min, SpO₂ 95% on 2 L/min nasal cannula; patient speaking in full sentences.
4. 0930: A. Gomez, RRT, reported nebulizer treatment completed at 0920. 0932: Patient improved following treatment.
Answer: 0930: A. Gomez, RRT, reported nebulizer treatment completed at 0920. 0932: On my assessment, RR 20/min, SpO₂ 95% on 2 L/min nasal cannula; patient speaking in full sentences.
The correct entry identifies the person reporting treatment completion and clearly separates that report from your assessment. The first entry presents completion without identifying how you learned about it, while the third leaves the individual source unclear and blurs whose assessment findings are documented. The fourth substitutes an unsupported conclusion about improvement for the actual findings.
At 0800, K. Davis, staffing coordinator, reports that an assignment for ordered continuous observation is pending. At 0805, you notify the charge RN and remain at the bedside pending coverage. At 0820, L. Brown, patient observer, arrives; you complete handoff, and Brown assumes continuous observation. Which entries accurately document these events without treating a request or notification as completed coverage? Select all that apply.
1. 0800: Spoke with K. Davis, staffing coordinator, regarding ordered continuous observation; Davis reported assignment pending.
2. 0805: Charge RN notified; I remained at bedside pending coverage.
3. 0805: Charge RN notified and assumed continuous observation pending arrival of the patient observer.
4. 0800: Continuous observation coverage established through staffing after discussion with K. Davis, staffing coordinator.
5. 0820: L. Brown, patient observer, arrived at bedside. Handoff completed; Brown assumed continuous observation.
Answer: 0800: Spoke with K. Davis, staffing coordinator, regarding ordered continuous observation; Davis reported assignment pending., 0805: Charge RN notified; I remained at bedside pending coverage., 0820: L. Brown, patient observer, arrived at bedside. Handoff completed; Brown assumed continuous observation.
The selected entries distinguish the pending assignment, your own bedside coverage, and the confirmed handoff to the observer. Documenting coverage as established at 0800 turns a pending assignment into a completed action. Notifying the charge RN at 0805 does not establish that the charge RN assumed observation.
At 1510, you report new disorientation to Dr. Patel, hospitalist, and request bedside evaluation. He advises continued observation and states that he will not attend at this time. Your concern remains unresolved, so at 1512 you notify the charge RN and contact the covering attending through the chain of command; the attending arrives at 1515. Which communication note best captures the concern, response, and follow-through?
1. 1510: Patient newly disoriented. Dr. Patel, hospitalist, aware; bedside evaluation requested. 1512: Charge RN notified and covering attending contacted through chain of command. 1515: Covering attending at bedside.
2. 1510: Dr. Patel, hospitalist, declined bedside evaluation. 1512: Concern unresolved; charge RN notified and covering attending contacted through chain of command. 1515: Covering attending at bedside.
3. 1510: Reported new disorientation to Dr. Patel, hospitalist, and requested bedside evaluation. He advised continued observation and stated he would not attend at this time. 1512: Concern unresolved; notified charge RN and contacted covering attending through chain of command. 1515: Covering attending at bedside.
4. 1510: Reported new disorientation to Dr. Patel, hospitalist, and requested bedside evaluation. He advised continued observation and stated he would not attend at this time. 1512: Charge RN aware. 1515: Covering attending at bedside.
Answer: 1510: Reported new disorientation to Dr. Patel, hospitalist, and requested bedside evaluation. He advised continued observation and stated he would not attend at this time. 1512: Concern unresolved; notified charge RN and contacted covering attending through chain of command. 1515: Covering attending at bedside.
The correct entry records the finding communicated, the specific request and response, and the escalation with confirmed bedside attendance. The first entry does not document Dr. Patel’s response, while the second omits the patient finding communicated and his advice to continue observation. The fourth leaves out your contact with the covering attending and uses the vague phrase 'Charge RN aware' instead of clearly recording your follow-through.

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