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

oxygen will be continued

the patient's coughing frequency will increase

cyanosis may be present

within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea

Answer and Explanation

The Correct Answer is D

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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Correct Answer is ["A","B"]

Explanation

A. Repeat the details of the prescription back to the provider: Verbal/telephone orders must be read back to ensure accuracy (known as read-back verification).

B. Record the reason for the call made to the provider and the results of the call in the Nurse’s Notes: Documentation should include:

Why the call was made
Provider’s response and order
Patient’s condition before and after intervention

C. Tell the charge nurse that the provider has prescribed morphine by telephone: While communication with the charge nurse is good practice, it does not replace proper documentation and verification.

D. Refuse to accept the verbal prescription because this is not an emergency: While verbal orders should be limited to emergencies, they can be accepted in certain non-emergency cases, provided read-back verification and documentation are done.

A. Every facility should have an approved abbreviations list. B. Creating abbreviations saves time for the person reading the chart. C. Writing out questionable abbreviations could make a jury think you're hiding something D. Abbreviating drug name and dosages helps reduce medication errors.

Correct Answer is A

Explanation

A. Every facility should have an approved abbreviations list. Hospitals and healthcare settings maintain a list of approved abbreviations to ensure consistency and prevent misinterpretation.

B. Creating abbreviations saves time for the person reading the chart: Unapproved abbreviations can lead to confusion and errors, potentially harming the patient.

C. Writing out questionable abbreviations could make a jury think you're hiding something: Avoiding abbreviations improves clarity, and using full words is preferred in legal documentation.

D. Abbreviating drug names and dosages helps reduce medication errors: Abbreviating drug names can cause dangerous medication errors (e.g., MS can mean morphine sulfate or magnesium sulfate). The Joint Commission prohibits certain abbreviations.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

Which of the following statements is correct about abbreviations?

Correct Answer is A

Explanation

A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:

Which part of the medical record can be used as evidence in court?

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:

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