The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

the insulin was administered based per the nurse's testimony

none of the answers are correct

the insulin was administered based on the witness testimony

the insulin was not administered because it was not charted

Answer and Explanation

The Correct Answer is D

A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.

B. None of the answers are correct: One of the answers is correct based on legal documentation principles.

C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.

D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.

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Correct Answer is B

Explanation

A. Validated data: While accurate data is crucial, validated data alone does not form a nursing diagnosis.

B. Data clustering: Data clustering involves grouping related signs, symptoms, and risk factors to determine patterns that lead to a nursing diagnosis.

C. Subjective data: Subjective data (e.g., pain, nausea) is part of assessment but must be combined with objective data to establish a diagnosis.

D. Objective data: Objective data (e.g., lab results, physical exam findings) is important, but a nursing diagnosis requires a comprehensive approach, including data clustering.

A. oxygen will be continued B. the patient's coughing frequency will increase C. cyanosis may be present D. within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea

Correct Answer is D

Explanation

A. Oxygen will be continued: Continuing oxygen therapy is an intervention, not a measurable outcome.

B. The patient's coughing frequency will increase: While coughing can help clear secretions, increased coughing does not necessarily indicate improved airway clearance.

C. Cyanosis may be present: Cyanosis is a sign of worsening oxygenation, not an improved outcome.

D. Within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea: A desired outcome should be specific, measurable, and indicate improvement. The resolution of dyspnea demonstrates effective airway clearance.

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The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

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Naxlex Comprehensive Predictor Exams

Which of the following assists the nurse in the identification of nursing diagnoses?

Correct Answer is B

Explanation

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:

Correct Answer is D

Explanation

The primary source of assessment information is:

JCAHO regulates standards of care to:

When documenting events in a patient's chart, the nurse should chart:

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

Select the type of assessment which is performed continuously throughout nurse-patient contact:

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

When discovering subjective data, recognize that they relate to:

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as: