A nurse is documenting a client’s admission assessment using a flow sheet.

Which of the following information should be included in a flow sheet?

(Select all that apply.).

Vital signs.

Allergies.

Medication administration.

Medical history.

Intake and output.

Answer and Explanation

Correct Answer : A,B,C,E

A flow sheet is a type of document that records routine and frequent data in a graphical or tabular form. It is used to monitor and evaluate the patient’s condition and response to treatment over time. A flow sheet should include information that is relevant, concise and easy to read.

• Choice A is correct because vital signs are one of the most common and important data that need to be recorded and monitored regularly for any patient.

• Choice B is correct because allergies are essential information that can affect the patient’s treatment plan and prevent adverse reactions.

• Choice C is correct because medication administration is another crucial data that shows what drugs, doses, routes and times the patient has received or will receive.

• Choice D is wrong because medical history is not a routine or frequent data that needs to be recorded in a flow sheet. Medical history is usually documented in a separate form that provides more details and background information about the patient’s past and present health conditions.

• Choice E is correct because intake and output are important data that indicate the patient’s fluid balance and renal function.

They need to be recorded and monitored regularly, especially for patients who have fluid restrictions.

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Correct Answer is D

Explanation

“I read back the order for a chest x-ray for Mr. Jones in room 20.”.

This is the best way to verify a telephone order from a radiologist, as it ensures that the nurse has accurately transcribed the order and that the radiologist has confirmed it.

Reading back the order also allows the nurse to clarify any doubts or questions about the order, such as the urgency, the reason, or the patient’s condition.

Choice A is wrong because it does not verify the order, but simply repeats it.

The nurse should not assume that the order is correct without confirmation from the radiologist.

Choice B is wrong because it asks the radiologist to repeat the order, which is inefficient and may cause confusion or errors.

The nurse should repeat the order to the radiologist, not the other way around.

Choice C is wrong because it uses a closed-ended question that can be answered with a yes or no, which may not reflect the radiologist’s true intention or understanding of the order.

The nurse should use an open-ended statement that requires the radiologist to acknowledge or correct the order.

According to federal regulations and accreditation standards, verbal and telephone orders should be authenticated by the prescriber within a specified time frame, usually 24 hours.Some states may have different or more stringent requirements, so nurses should be familiar with their state laws and regulations.Verbal and telephone orders should also be documented and signed by two nurses or one nurse and one enrolled endorsed nurse for verification and administration.

A. Specifies the plan of care for clients with different diagnoses. B. Provides guidelines for managing clients with similar health problems. C. Describes the roles and responsibilities of each member of the health care team. D. Evaluates the quality and cost-effectiveness of care delivered to clients.

Correct Answer is B

Explanation

A critical pathway provides guidelines for managing clients with similar health problems.According to the definition from Wikipedia, a critical pathway is one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes.It has been shown that their implementation reduces the variability in clinical practice and improves outcomes.

Choice A is wrong because a critical pathway does not specify the plan of care for clients with different diagnoses, but rather for a specific group of patients with a predictable clinical course.Choice C is wrong because a critical pathway does not describe the roles and responsibilities of each member of the health care team, but rather defines, optimizes and sequences the different tasks (interventions) by the professionals involved in the patient care.Choice D is wrong because a critical pathway does not evaluate the quality and cost-effectiveness of care delivered to clients, but rather aims to promote organised and efficient patient care based on evidence-based medicine.

Normal ranges for COPD are: FEV1/FVC ratio < 0.7; FEV1 < 80% predicted; FVC normal or reduced; TLC > 80% predicted; RV > 120% predicted; DLCO < 80% predicted.

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A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

Correct Answer is D

Explanation

A nurse is reviewing a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

Correct Answer is B

Explanation

A nurse is working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

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Which of these statements about documentation are true? (Select all that apply.).

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A nurse is using a computerized documentation system in a health care facility. Which of the following actions should the nurse take to ensure confidentiality and security? (Select all that apply.).

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A nurse is documenting a client’s admission assessment using a flow sheet.

Which of the following information should be included in a flow sheet?

(Select all that apply.).