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 B

Explanation

A. Block: Block charting documents everything over a set period (e.g., entire shift), rather than only changes.

B. By exception: Charting by exception (CBE) means only documenting significant changes in condition or treatment rather than routine care.

C. Focused: Focused charting documents care related to a specific problem, not just exceptions.

D. SOAP: SOAP (Subject

A. the specific time of all sudden changes in the patient's condition B. the period the shift covers C. every 2 hours D. every hour on the hour

Correct Answer is A

Explanation

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

Correct Answer is B

Explanation

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

Correct Answer is A

Explanation

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Which of the following statements is correct about abbreviations?

What is the major concern when using a computer for documentation?

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

Patient health care records are:

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

JCAHO regulates standards of care to: