A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

A. Evaluation, planning, assessment, implementation: Evaluation is the last step, not the first.

B. Assessment, planning, implementation, evaluation
The correct order of the nursing process is:

1. Assessment – Gather data

2. Planning – Develop goals and interventions

3. Implementation – Carry out the plan

4. Evaluation – Determine effectiveness and adjust as needed

C. Implementation, assessment, planning, evaluation: Assessment must come first before implementing any plan.

D. Planning, evaluation, assessment, implementation: Planning comes after assessment, and evaluation is last, not second.

A. Teaching deep breathing and relaxation techniques as needed: Teaching non-pharmacological pain relief (such as deep breathing) is an independent nursing action that does not require a physician’s order.

B. Inserting a nasogastric tube (NG) to relieve gastric distention: NG tube insertion requires a physician's order, making it not independent.

C. Placing the nurse call button within reach at all times: Ensuring the patient’s call button is within reach is an independent nursing action to promote safety and communication.

D. Giving hand massages daily: Nurses can provide non-invasive comfort measures such as hand massages without a physician's order.

E. Repositioning the patient every 2 hours to reduce pressure injury risk: Repositioning is an independent intervention that prevents skin breakdown and pressure injuries.

F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed: Medication administration requires a physician’s order, making it a dependent nursing action.

A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.

B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.

C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.

D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.

A. CNA (Certified Nursing Assistant): CNAs assist with basic patient care (e.g., hygiene, vital signs) but do not perform assessments or make nursing diagnoses.

B. Technician: Technicians perform specific tasks (e.g., drawing blood, ECGs) but do not analyze patient data for diagnosis.

C. RN (Registered Nurse): The RN is responsible for analyzing and interpreting data, identifying nursing diagnoses, and developing the care plan.

D. LPN/LVN (Licensed Practical/Vocational Nurse): LPNs/LVNs can collect data but cannot make a nursing diagnosis, which is the RN’s role.

A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.

B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.

C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.

D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.

E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.

A. The patient's friends: While family and friends can provide secondary information, they are not the primary source of assessment data.

B. Past medical records: Past records can provide valuable history, but they do not replace real-time data from the patient.

C. The patient's record: The medical record is a collection of past documentation but is not a source of new assessment data.

D. The patient: The patient is the primary source of assessment data, as they provide information about their symptoms, medical history, and concerns.

A. Patient provided data: Subjective data includes information the patient states, such as symptoms, pain level, or concerns.

B. All of the answers are correct: Not all answer choices describe subjective data.

C. Observed data: Observations made by the nurse (e.g., swelling, pallor) are objective, not subjective.

D. Measured data: Measurable data, such as vital signs, are objective, not subjective.

A. The patient is vulnerable to develop the problem: This describes a risk diagnosis, where the patient has the potential to develop a condition but does not currently have it.

B. There is no evidence of defining characteristics: An actual nursing diagnosis must have defining characteristics (symptoms/signs).

C. A condition is currently present: An actual nursing diagnosis means the condition is already present, with observable signs and symptoms.

D. It is written as a two-part statement: Actual nursing diagnoses use a three-part statement:

1. Problem (diagnosis)

2. Etiology (cause)

3. Signs and Symptoms (evidence)

A. Physician's Order Sheet: While the physician orders narcotics, administration is not documented here.

B. Narcotic Administration Sheet: The Narcotic Administration Sheet is specifically for controlled substances, ensuring proper tracking and preventing misuse.

C. Care Plan: The care plan outlines patient goals and interventions, not medication administration.

D. MAR (Medication Administration Record) and Narcotic Administration Sheet: The MAR (Medication Administration Record) documents all medications given to the patient. The Narcotic Administration Sheet is required for controlled substances to comply with regulations.