WCTC College Module 2 Communication and Documentation Quiz

LPN Progression Transition

Module 2 Communication and Documentation Quiz

Question 1Which action by the nurse is a nonverbal behavior that enhances communication?

Maintaining a distance of 6 to 12 inches

 Asking mostly open-ended questions

 Keeping a neutral expression on the face

Sitting down to speak with the patient

 Question 2What is the primary purpose of communication?

Exchange information

 Form relationships

 Establish therapeutic rapport

Meet primarily psychosocial needs

 Question 3The nurse is caring for a patient after abdominal surgery and notices that the urine is blood tinged. The nurse places a call to the physician regarding the color of the urine. When communicating to the physician using the SBAR format, which statement by the nurse below best describes the “R” in SBAR?

   “I’m calling to let you know I ordered and sent a urinalysis for this patient.”

 “Your patient just had surgery, and I’ve noticed some blood-tinged urine in the Foley catheter.”

 "Your patient has blood-tinged urine after surgery. I suggest that we obtain a urinalysis for this patient.”atient has blood-tinged urine after surgery. I suggest that we obtain a urinalysis for this patient.”

 “Hello, my name is Susan, and I’m calling about your patient who just had abdominal surgery.”

Question 4A patient tells the nurse, “I’m having a lot of pain in my hip.” Which responses by the nurse most likely would stimulate the patient to provide the most complete data? Select all that apply.

 “Is your pain severe?”

  “Tell me about your pain.”

 “How would you describe your pain?”

"Is your pain better or worse than it was this morning?”

 “Do you need pain medicine?”

Question 5Which statements are reflective of barriers to communication? Select all that apply.

   I see you had a heart attack. Why are you still smoking?”

   “I know you are having pain in your knee. I will check your vital signs before getting your pain medications.”

    “Let’s talk about all the possible causes and treatments for chest pain.”

 “Tell me a little more about the chest pain you were having at home.”

 “The nursing assistant told me you are having back pain. I’ll get your pain medication now.”

 Question 6Which instruction is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning?

Purchase medication in child-resistant containers.

 Take medications in front of the child, and explain that they are for adults only.

 Store medications on countertops out of the child’s reach.

 Never leave the child unattended around medications or cleaning solutions.

 Question 7Which is the most commonly reported incident in hospitals?

Treatment delays

 Laboratory specimen errors

 Equipment malfunction

 Patient falls

 Question 8The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which statement would the nurse use to best describe a sentinel event?

An unexpected event involving death or serious physical or psychological injury

 An event that can cause serious injury to a patient that should never happen in a hospital

 Operating room event involving the use of unsafe equipment

 Specific events that enable a hospital to maximize reimbursement

 Question 9A patient refuses a dose of medication. How should the nurse document the event?

   Patient refuses the 0900 dose of digoxin.

Patient is uncooperative and refuses the prescribed dose of digoxin.

 Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin.

    0900 dose of digoxin not given

  Question 10A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. Which type of charting is the nurse using?

Charting by inclusion

 Narrative charting

 Charting by exception

 Source-oriented charting

 Question 11The implementation of electronic health records (EHRs) allows the nurse to carry out which actions? Select all that apply.

Promote efficient use of time spent charting.

Activate the system’s safeguards to improve quality of care.

 Use data to facilitate evidence-based nursing practice.

Reduce the opportunity for interdisciplinary collaboration.

Access patient information at the same time as other team members

 Question 12The electronic health record (EHR) is used to document client care. Which purposes are applicable to the EHR? Select all that apply.

Provides continuity of care

Acts as an occurrence report

Is used for quality improvement

 Is a legal record

 Is used for utilization review

Question 13A 65-year-old patient is admitted to your unit with an exacerbation of chronic obstructive pulmonary disease. After he’s settled into bed, you begin asking about his health history. Which of the following should you include in a health history?

   Medical Diagnosis

Health History

your opinion of his chief complaint

Your best advice on his illness

 Question 14A 72-year-old patient is admitted to your unit with a fever of unknown origin. You complete the health history and the admission physical assessment. From this data, you begin making your nursing diagnosis. Which components should you include?

Evaluation

Expected outcome

 Medical diagnosis

 Human response or problem

 Question 15You’re concerned about your patient’s sleeping patterns. How should you document your findings?

Patient appears to sleep a lot

Pt. appears to have slept from 2200 to 1200

Patient sleeps a lot

Patient sleeps deeply

 Question 16The nurse caring for your patient on the previous shift identified impaired physical mobility as a nursing diagnosis for the patient. One of the expected outcomes states, “The patient will ambulate unassisted by 6/12/08.” Which element of the outcome hasn’t been included?

Time

Condition

 Behavior

 Measure

Question 17When using narrative charting, you document the following statements for a patient who recently underwent exploratory abdominal surgery: Pt. states that incisional pain is unrelieved 30 min. after administration of analgesic. He’s grimacing and holding his incision site. This documented observation is an example of

A change in the patient's condition

A lack of improvement in the patient's condition

 The patient's response to teaching

 the patient’s response to a treatment or medication.

 Question 18A health care provider gives you a verbal order for digoxin 0.25 mg P.O. for your patient. How should you document it?

   Don’t record anything. Wait for the health care provider to come by later and supply a written order.

 Record the order on the health care provider’s order sheet and read it back.

Include the health care provider’s prescriber number in the order.

 Sign the health care provider's name

 Question 19An 81-year-old patient admitted with dehydration requires I.V. therapy. After establishing I.V. access, you must

document

Only the date and time you established I.V. access.

 Only the name of the catheter you used

 Only the number of venipuncture attempts you made

 

   the date, time, and venipuncture site; type and gauge of the catheter; and number of venipuncture attempts you made.

 Question 20Which abbreviations are on The Joint Commission’s Do not use list? Select all that apply.

mg

 NPO

 IU

QD