NCLEX FUNDAMENTALS PROCTORED EXAM
A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all that apply
- Cover errors w/correction fluid, & write in the correct info
- Put the date & time on all entries
- Document objective data, leaving out opinions
- Use as many abbreviations as possible
- Wait until the end of the shift to document
- The physical therapist didn't ambulate the client today
- The skin barrier's seal stays on in bed but loosens when the client stands.
- The client seemed to welcome having a "day off" from physical therapy
- The wound care nurse will see the client later today
- The client ate all the food on her lunch tray
B, C The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today.The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today.The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all that apply.
A, B, D
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate?Select all that apply.
- Repeat the details of the prescription back to the provider
- Have another nurse listen to the telephone prescription
- Obtain the prescriber's signature on the prescription within 24hrs This study source was downloaded by 100000774780401 from CourseHero.com on 08-11-2021 04:27:32 GMT -05:00
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- Decline the verbal prescription because it is not an emergency situation
- Tell the charge nurse that the provider has prescribed morphine by telephone
A, B, C
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him?
- Registered dietitian
- Occupational therapist
- Physical therapist
- Social worker
- social worker
- Social worker
- Certified nursing assistant
- Registered dietitian
- Occupational therapist
- Registered dietitian
- Occupational therapist
Rational: A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home lO Mo A RcPS D| 64 5 72 22 A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the inter-professional care team?
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