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

the specific time of all sudden changes in the patient's condition

the period the shift covers

every 2 hours

every hour on the hour

Answer and Explanation

The Correct Answer is A

A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.

B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.

C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.

D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).

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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. to clarify nursing principles B. to resolve the patient's problems C. to support physician's orders D. to provide broad, general statements

Correct Answer is B

Explanation

A. To clarify nursing principles: Nursing orders are action-oriented and not just meant to clarify theoretical principles.

B. To resolve the patient’s problems: Nursing orders focus on patient care interventions that directly address identified problems in the nursing diagnosis.

C. To support physician’s orders: Nursing orders complement medical care but are independent nursing actions, not just support for physician directives.

D. To provide broad, general statements: Nursing orders should be specific, measurable, and actionable, not broad statements.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

Clarify the primary purpose of nursing orders:

Correct Answer is B

Explanation

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

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

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

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:

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

When discovering subjective data, recognize that they relate to:

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: