1110 Exam 2 Review w/ practice quiz

Vocabulary flashcards covering ethical principles, documentation methods, QSEN, clinical judgment, evidence-based practice, safety, and quality improvement concepts presented in the lecture.

Multimodal Pain Management

Using two or more complementary interventions (e.g., pharmacologic and non-pharmacologic) to control pain, such as acetaminophen plus guided imagery.

FLACC Scale

Behavioral pain-assessment tool (Face, Legs, Activity, Cry, Consolability) for non-verbal or pediatric patients.

SOAP Documentation

Charting format with four parts: Subjective, Objective, Assessment, Plan.

SBAR Communication

Structured hand-off format: Situation, Background, Assessment, Recommendation.

Recommendation (in SBAR)

The section where the nurse states what should happen next (e.g., suggest removing a Foley catheter).

DAR Documentation

Charting format with Data, Action, Response (patient outcome).

Response ("R" in DAR)

Patient’s reaction or outcome following the nursing action documented.

Narrative Notes

Traditional, story-like chronological documentation without a structured format.

Cultural Competence

Ability to deliver care that respects and integrates a patient’s cultural beliefs and language needs (e.g., securing an interpreter).

Fidelity

Ethical principle of keeping promises and commitments to patients.

Beneficence

Ethical duty to actively do good for the patient (e.g., repositioning an unconscious patient).

Autonomy

Respecting the patient’s right to make informed choices about their care.

Justice (Ethical Principle)

Fair and equal distribution of resources and care (e.g., giving pain medicine equitably).

HIPAA

U.S. law protecting patient privacy and confidentiality of health information.

Nurse Practice Act

State legislation that defines nurses’ scope of practice and legal responsibilities.

QSEN Competencies

Quality and Safety Education for Nurses skills; include safety, informatics, teamwork, etc.

QSEN Informatics

Competency involving use of technology and information systems to improve patient care.

Clinical Judgment Model – Noticing

First step where the nurse observes cues (e.g., noticing a patient grimacing while walking).

Clinical Decision Support System (CDSS)

EHR feature that provides alerts or recommendations (e.g., drug-interaction warning).

Root Cause Analysis

Structured process to identify underlying factors that led to an event, often using PDSA.

Plan-Do-Study-Act (PDSA) Cycle

Quality-improvement model for testing and refining changes to improve care.

PICOT Format

Structured clinical question for evidence-based research: Patient/Problem, Intervention, Comparison, Outcome, Time.

Evidence-Based Practice – Currency

Using the most up-to-date research evidence in clinical decision-making.

Dimensional Analysis

Systematic method for drug-dosage calculations to reduce arithmetic errors.

Morse Fall Scale

Validated tool to assess a patient’s risk of falling.

Fall-Prevention Gait Belt

Safety device placed around a patient’s waist to support safe ambulation.

Delegation – Unstable Patient

Vital signs for a new admission with dyspnea should not be delegated to a CNA.

Shared Decision-Making

Interprofessional team collaborates with the patient to develop the plan of care (e.g., discharge planning).

Clinical Judgment Model – Responding

Implementing nursing actions based on interpreted data (e.g., assisting a CNA mid-transfer to prevent injury).

Therapeutic Communication

Purposeful use of open-ended questions, reflection, and validation—avoids giving personal advice.

Non-Pharmacologic Nausea Management

Interventions such as offering small, frequent meals or ginger tea instead of drugs.

Pressure-Ulcer Prevention

Priority nursing action of repositioning an immobile patient at least every two hours.

Nursing Process – Assessment

First step involving systematic data collection about the patient’s condition.

Nursing Process – Evaluation

Determining the patient’s response to interventions (e.g., reassessing pain 30 minutes post-medication).

Medical vs. Nursing Diagnosis

Medical labels disease (pneumonia); nursing diagnosis states patient problem in plain language (impaired oxygenation from fluid in lungs).

SOAP vs. DAR

Two common charting formats—SOAP (Subjective, Objective, Assessment, Plan) and DAR (Data, Action, Response).

Clinical Documentation – Timeliness

Entries must be current; documenting care before it occurs is inappropriate.

Licensure

Legal authorization that permits a nurse to practice and protects public safety.

CDSS Alert Response

Nurse should consider clinical judgment and consult the provider before acting on automated recommendations.

Integrity in Scholarship

Properly citing sources to avoid plagiarism, such as using correct APA format.

Justice

Ensuring equitable distribution of nursing resources and treatments among patients.

1. A nurse is caring for a patient in acute pain. Which intervention best reflects a multimodal approach to pain management?
 A. Administering morphine sulfate IV only
 B. Offering ginger tea and a back massage
 C. Providing acetaminophen and guided imagery
 D. Instructing the patient to rate pain using FLACC scale

C

2. A client recovering from hip surgery asks, “Why do I need to get out of bed so soon?” The nurse’s best response demonstrates understanding of:
 A. Patient’s pain tolerance
 B. Ethical obligations
 C. Risks of immobility
 D. Client autonomy

C

3. A nurse preparing a dose of furosemide needs to convert 2 g to mg. Which is the correct amount?
 A. 0.02 mg
 B. 20 mg
 C. 200 mg
 D. 2000 mg

D

4. A nurse evaluates documentation in a patient's chart. Which note best demonstrates SOAP format?
 A. "Patient ate 75% of lunch and denied nausea."
 B. "Subjective: Headache; Objective: BP 148/92; Assessment: Hypertension; Plan: Monitor BP."
 C. "Pain 4/10, repositioned to left side, tolerated well."
 D. "Administered 325 mg acetaminophen for headache."

B

5. During shift handoff, a nurse uses SBAR. Under "Recommendation", the nurse should include:
 A. The patient’s latest lab results
 B. A suggestion for a Foley catheter removal
 C. The patient’s date of birth
 D. The medication administration record

B

6. A nurse advocates for an interpreter for a non-English speaking patient. This action supports:
 A. Fidelity
 B. Cultural competence
 C. Ethical dilemma
 D. Advanced planning

B

7. A new nurse is practicing the Noticing step of the Clinical Judgment Model. Which action reflects this?
 A. Evaluating lab results after administration of insulin
 B. Identifying patient grimacing while walking
 C. Educating patient about fall prevention
 D. Changing care plan due to lack of progress

B

8. Which communication technique should a nurse avoid during a therapeutic conversation?
 A. Asking open-ended questions
 B. Reflecting the patient’s feelings
 C. Offering personal advice
 D. Validating emotions

C

9. The nurse determines the nursing diagnosis: "Impaired oxygenation due to pneumonia". This is an example of:
 A. Risk factor identification
 B. Priority clinical problem
 C. Medical diagnosis
 D. Objective data

B

10. A nurse updating a patient’s chart uses DAR documentation. What does the "R" represent?
 A. Report
 B. Reaction
 C. Response
 D. Review

C

11. A patient complains of nausea after chemotherapy. Which response shows a priority nursing intervention?
 A. “This is a common side effect; you’ll be okay.”
 B. “Would you like to try sipping ginger tea or ice chips?”
 C. “I’ll tell your doctor to stop the chemotherapy.”
 D. “Take deep breaths and focus on something else.”

B

12. A nurse identifies a pressure ulcer on a bedridden patient. What initial nursing action is best?
 A. Notify the physician
 B. Document the finding
 C. Reposition the patient
 D. Apply hydrocolloid dressing

C

13. A student nurse asks the instructor about HIPAA. The correct explanation is:
 A. “HIPAA protects a nurse’s documentation.”
 B. “HIPAA ensures patient access to all federal insurance.”
 C. “HIPAA prevents workplace injuries.”
 D. “HIPAA safeguards patient confidentiality.”

D

14. A nurse documents a patient’s condition using narrative notes. This is an example of:
 A. SOAP documentation
 B. DAR format
 C. Traditional charting
 D. SBAR communication

C

15. A patient on bedrest asks why they need to do leg exercises. The nurse explains the importance of preventing:
 A. Muscle growth
 B. Deep vein thrombosis
 C. Blood sugar spikes
 D. Renal calculi

B

16. Which action by a nurse demonstrates the ethical principle of beneficence?
 A. Protecting the patient’s right to refuse surgery
 B. Ensuring equal care for patients regardless of income
 C. Repositioning an unconscious patient every 2 hours
 D. Documenting honestly in the patient chart

C

17. Which situation would require the use of clinical decision support systems (CDSS) in the EHR?
 A. Sending an email to the patient’s provider
 B. Entering daily intake and output
 C. Alert for potential drug interaction
 D. Reviewing nurse shift schedule

C

18. A patient recovering from a stroke begins walking with a walker. Which fall prevention strategy is most appropriate?
 A. Raise all side rails
 B. Keep bed in lowest position
 C. Use gait belt during ambulation
 D. Place call light out of reach

C

19. A nurse delegates vital signs to a CNA. Which patient should not be delegated?
 A. Post-op day 3 hip replacement
 B. Stable patient on telemetry
 C. New admission with shortness of breath
 D. Diabetic patient before meals

C

20. A nurse receives a complaint about unprofessional Facebook posts. What principle is most likely violated?
 A. QSEN informatics
 B. SBAR communication
 C. HIPAA
 D. Fidelity

C

21. A nurse teaching a group of students about QSEN competencies emphasizes that "informatic skills" involve:
 A. Reducing medication errors manually
 B. Effective delegation and teamwork
 C. Using technology to improve patient care
 D. Leading ethical committees

C

22. A client is diagnosed with cancer and says, “I feel like giving up.” The nurse’s best therapeutic response is:
 A. “Don’t say that—you need to stay strong.”
 B. “Why would you feel that way?”
 C. “Tell me more about what you're feeling.”
 D. “You’ll get through this eventually.”

C

23. Which nurse action supports the principle of autonomy?
 A. Explaining the purpose of a treatment and offering choices
 B. Choosing treatment based on what the nurse feels is best
 C. Convincing the patient to proceed with surgery
 D. Delaying consent for a procedure

A

24. During a root cause analysis, the team is identifying factors that led to a fall. This is part of which QI process?
 A. Plan
 B. Do
 C. Study
 D. Act

A

25. A nurse notices an IV site is red and swollen. According to the CJMM, what step is this?
 A. Reflecting
 B. Responding
 C. Interpreting
 D. Noticing

D

26. The nurse must document a wound dressing change. Which of the following is the most appropriate entry?
 A. “Wound looked good.”
 B. “Dressing changed.”
 C. “4 cm x 2 cm ulcer; pink granulation tissue; dressing changed per order.”
 D. “No complaints from the patient.”

C

27. A nursing student uses an outdated article for a research paper. Which aspect of evidence-based practice (EBP) is violated?
 A. Validity
 B. Relevance
 C. Currency
 D. Reliability

C

28. A nurse encounters a situation with competing ethical values. This is best described as a(n):
 A. Breach of justice
 B. Legal violation
 C. Ethical dilemma
 D. Fidelity failure

C

30. What is the nurse’s best action when a confused patient attempts to leave the bed unassisted?
 A. Use all four side rails
 B. Place the patient in a vest restraint
 C. Stay with the patient and call for assistance
 D. Let the patient attempt ambulation

C

31. Which of the following best illustrates shared decision-making in interprofessional collaboration?
 A. The nurse independently updates the care plan
 B. Physician makes all decisions for the team
 C. Team develops discharge plan with patient input
 D. Pharmacist educates patient alone

C

32. Which action violates the Nurse Practice Act?
 A. Administering medication under a physician’s order
 B. Documenting patient care after delivery
 C. Performing a procedure outside of the nurse’s scope
 D. Calling a physician about lab results

C

33. A student nurse turns in a paper without citing their sources. This violates:
 A. Informatics
 B. APA Format
 C. QSEN Safety
 D. Fidelity

B

34. A nurse questions a provider’s unusual medication dosage. This demonstrates which QSEN competency?
 A. Quality improvement
 B. Teamwork and collaboration
 C. Safety
 D. Informatics

C

35. The primary purpose of the PICOT format is to:
 A. Identify patient vital signs
 B. Guide evidence-based research
 C. Interpret EKG findings
 D. Structure nursing diagnoses

B

36. A nurse evaluates the effect of pain medication 30 minutes after administration. This step corresponds with:
 A. Planning
 B. Evaluation
 C. Diagnosis
 D. Implementation

B

37. A patient with limited mobility is at risk for pressure ulcers. Which action is a nursing priority?
 A. Obtain dietary preferences
 B. Encourage oral fluid intake
 C. Reposition patient every 2 hours
 D. Provide spiritual support

C

38. The Morse Fall Scale is used to:
 A. Evaluate oxygenation status
 B. Determine level of sedation
 C. Assess patient fall risk
 D. Screen for dementia

C

39. A nurse using dimensional analysis for dosage calculation ensures:
 A. Faster documentation
 B. Fewer administration steps
 C. Reduced calculation errors
 D. Enhanced IV site checks

C

40. Which nursing diagnosis is written in plain language?
 A. Pneumonia
 B. Impaired oxygenation from fluid in lungs
 C. Ineffective gas exchange
 D. COPD

B

41. Which intervention best demonstrates non-pharmacologic management of nausea?
 A. Administer ondansetron
 B. Give promethazine
 C. Suggest small, frequent meals
 D. Start IV fluids

C

42. What is the nurse’s best response when a patient says, “I’m afraid I’ll never walk again”?
 A. “Try to be positive.”
 B. “You should think about therapy.”
 C. “That must be very hard to think about.”
 D. “You’ll recover in no time.”

C

43. The nurse encourages the use of a walker for a post-op patient. This promotes:
 A. Veracity
 B. Ethical fidelity
 C. Mobility and safety
 D. Patient isolation

C

44. Which of the following examples best reflects the justice principle?
 A. Explaining all risks before a procedure
 B. Ensuring pain meds are distributed equally
 C. Avoiding harm to a confused patient
 D. Acting according to a promise

B

45. Which action during documentation is inappropriate?
 A. Using exact time and date
 B. Documenting in advance
 C. Including patient response
 D. Writing legibly and clearly

B

46. What is the first step in the nursing process?
 A. Diagnosis
 B. Implementation
 C. Planning
 D. Assessment

D

47. The purpose of licensure in nursing is to:
 A. Define patient satisfaction
 B. Ensure legal right to practice
 C. Allow medication administration
 D. Set hospital policies

B

48. A nurse notes the CDSS recommends labs be repeated. The nurse should:
 A. Ignore it
 B. Immediately order labs
 C. Review clinical judgment and consult provider
 D. Restart computer

C

49. Which is an example of using fidelity in nursing?
 A. Adhering to patient wishes
 B. Delivering bad news compassionately
 C. Following through on promises made
 D. Keeping documentation secure

C

50. A nurse on a QI committee suggests using the Plan-Do-Study-Act (PDSA) cycle. What is the primary goal?
 A. Increase staff performance reviews
 B. Implement personal improvement plans
 C. Test and improve quality of care
 D. Track medication errors

C

29. A nurse observes a CNA transferring a patient incorrectly. What is the nurse's priority action?
 A. Report to administration
 B. Assist immediately to prevent injury
 C. Document in the chart
 D. Ignore if no injury occurred

B