Question 15
Type: MCSA
Before providing care, the nurse reviews the client’s pertinent history, daily treatments, diagnostic procedures,
allergies, problems, and other information. Which form should the nurse review to learn all of this information?
1. The client’s medical record
2. The MAR (medication administration record)
3. The written care plan
4. The Kardex
Question 16
Type: MCSA
The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse
rewrite for this client?
1. Lasix, 20 mg, po bid
2. Lasix, 20 mg tablet, twice daily
3. Lasix, 20 mg by mouth, two times a day a day
4. Lasix, 20 mg by mouth 8 AM and 2 PM
Question 17
Type: MCSA
A client in long-term care is scheduled for a review of the assessment and care screening process. Where should
the nurse document this information?
1. MDS
2. OBRA
3. CBE
4. Kardex
Question 18
Type: MCSA
When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs.
Which chart entry should the nurse document for this finding?
1. Client fell out of bed, but did push the call button for assistance.
2. Client became tangled in the bed linens, then called for assistance after falling out of bed.
3. Recorder responded to client’s call light, upon entering the room, found client on floor.
4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.
Question 19
Type: MCSA
After completing the client care and documenting it in the progress notes, the nurse realizes that documentation
was placed on the wrong medical record. What should the nurse do?
1. Use white-out over the mistake.
2. Take a wide permanent marker and blacken out all the documentation.
3. Put an “X” through the entire page, identify it as an “error,” initial, and move on to the correct chart.
4. Draw a single line through the documentation, write “mistaken entry” next to the original entry, and initial it.
Question 20
Type: MCMA
The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing
computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing
this type of system?
Standard Text: Select all that apply.
1. The system is relatively inexpensive to maintain.
2. Bedside terminals eliminate worksheets and note taking.
3. The system links to various sources of client information.
4. The system better protects client privacy.
5. Information is legible.
6. Results, requests, and client information can be sent and received quickly.
Question 21
Type: MCSA
The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack.
When utilizing focus charting, in which section should the nurse document this information?
1. Data (D)
2. Action (A)
3. Response (R)
4. Planning (P)
Question 22
Type: MCMA
The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client
care. Which actions should the nurse take to prove adherence?
Standard Text: Select all that apply.
1. Charting the client’s response to pain medication taken
2. Describing the client as “appearing to be comfortable”
3. Leaving sufficient charting space for the previous shift to chart client teaching
4. Documenting that the client reports, “I’m so afraid of tomorrow’s surgery”
5. Making a late entry regarding a client’s request for pain medication
Question 23
Type: MCMA
The nurse is documenting care provided to a client. Which action should the nurse take to demonstrate the
avoidance of potentially confusing abbreviations when documenting?
Standard Text: Select all that apply.
1. Documenting vital signs as “TPR.”
2. Charting that the “drsg was dry and intact.”
3. Transcribing a verbal order as “Carbamazepine 12 mcg/ml IV push daily.”
4. Documenting “Client consistently requesting IM MS for pain well before prescribed time.”
5. Charting, “Client to be ambulated q.i.d.”
New Questions:
Question 24
Type: MCMA
The nurse is using I-SBAR to provide a report to an intensive care nurse for a client transfer. Which statements
indicate that the nurse is using this communication technique appropriately?
Standard Text: Select all that apply.
1. “Mr. Collins has a history of peptic ulcer disease.”
2. “Hi Susan, my name is Janie and I’ve been taking care of Mr. Collins all day.”
3. “It’s no wonder he’s bleeding from his stomach; he drinks a six pack of beer every day.”
4. “Late this morning Mr. Collins became nauseated and vomited 250 mL of bright red emesis.”
5. “He has bowel sounds in all 4 quadrants, is not experiencing any pain, but has a heart rate of 110 and blood
pressure of 98/50 mm Hg.”
Question 25
Type: MCMA
A client’s condition has deteriorated and the nurse needs to notify the health care provider. What information
should the nurse include when providing a telephone report on this client?
Standard Text: Select all that apply.
1. Client’s medical diagnosis
2. Name of unit nurse manager
3. Names of family members visiting
4. Name and relationship to the client
5. Observed changes in the client’s status
