Question

A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use?(Select all that apply.)

Answer 1

Correct Answers:

30 mL
Bid
2mg

Rationale :

✅Only standard, approved abbreviations should be used in documentation to prevent misinterpretation and ensure patient safety.

30 mL is a standard unit of measurement.
Bid means “twice a day,” an accepted abbreviation.
2 mg uses appropriate spacing and metric unit format.

✅Avoid abbreviations like “MS04”, which are considered error-prone because they may be misread or confused with other drugs like morphine sulfate or magnesium sulfate.

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Answer 2

Correct Answers:

Advocate

Rationale :

🔹The nurse’s role as an advocate involves protecting client rights, supporting their autonomy, and ensuring informed decision-making.

🔹Advocacy includes speaking on behalf of the client when they are unable to and ensuring their wishes are respected in the healthcare setting, particularly regarding procedures, medications, and ethical decisions.

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Answer 3

Correct Answers:

Surgeon

Rationale :

📌Obtaining informed consent is the legal and ethical responsibility of the surgeon performing the procedure.

📌This includes explaining the nature, purpose, risks, benefits, and alternatives of the surgical intervention.

📌The nurse may witness the signature but cannot obtain or explain the procedure unless specifically delegated by the provider under legal guidelines.

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Answer 4

Correct Answers:

Code status

Rationale :

✍In the SBAR (Situation, Background, Assessment, Recommendation) communication model, the Background section includes essential clinical details that provide context for current care decisions.

✍Code status (e.g., Full Code, DNR) is a critical element because it defines the scope of emergency interventions the client should receive.

✍Including code status ensures all team members are aware of the client's resuscitation preferences, which is vital for safe, ethical, and timely care planning, particularly in acute or high-risk situations like traumatic brain injuries.

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Answer 5

Correct Answers:

Drop prescribed amount of medication into the conjunctival sac.

Rationale :

🟣Administering eye drops into the conjunctival sac ensures that the medication is placed in a safe, non-irritating area of the eye where it can be properly absorbed.

🟣This technique prevents direct contact with the cornea, which is highly sensitive, and minimizes the risk of corneal injury.

🟣Proper placement also reduces systemic absorption and promotes therapeutic effectiveness of the ophthalmic medication.

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Answer 6

Correct Answers:

Question any part of the order that is unclear or inappropriate_
Transcribe the order into the client's health record.
Repeat the order back to the provider.
Obtain the provider's signature within 8 hr.

Rationale :

💎For telephone prescriptions, safety and legal accuracy depend on these steps:

Clarify anything ambiguous to ensure the order is appropriate and safe.
Repeat back the complete order to confirm understanding and prevent miscommunication.
Transcribe it into the health record immediately to ensure proper documentation.
Obtain a signature from the prescribing provider within the legally required time frame, typically 8 to 24 hours, to meet regulatory compliance and institutional policies.

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Answer 7

Correct Answers:

Administer pain medication to the first client.

Rationale :

✅Using principles of clinical judgment, the nurse should prioritize unrelieved pain first, especially when reported at a level of 6 out of 10.

✅Pain management is essential because unmanaged pain can lead to physiological stress, poor surgical recovery, and reduced mobility, all of which impact healing.

✅Addressing pain promptly improves client comfort, promotes participation in care, and aligns with the ethical principle of beneficence.

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Answer 8

Correct Answers:

"l will begin upon the client's admission to the facility"

Rationale :

♦Effective discharge planning begins at admission to ensure that client education, equipment needs, home support, and follow-up care are addressed early.

♦This process enables coordinated, individualized plans that reduce hospital stays and prevent readmissions.

♦It also allows nurses to educate clients progressively and adapt the plan of care as the client’s condition evolves.

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Answer 9

Correct Answers:

Pull the auricle down and out.

Rationale :

🔹In children under 3 years old, the ear canal is shorter and more horizontal.

🔹Pulling the auricle down and out helps straighten the ear canal, allowing medication to flow more directly and safely toward the tympanic membrane.

🔹This positioning facilitates effective medication delivery while minimizing discomfort and risk of injury.

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Answer 10

Correct Answers:

Document that the client refuses the medications.

Rationale :

▶If a client refuses medication, the nurse must respect the client’s right to autonomy and document the refusal accurately.

▶This includes noting the medication, time, and any reason the client provided.

▶Objective documentation supports communication with the healthcare team and provides a legal record of the client’s decision, while upholding ethical standards in nursing care.

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RN Nur 104 Final Assessment Fundamentals

No.

1 : A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use?(Select all that apply.)

2 : A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions?

3 : A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

4 : A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

5 : A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take?

6 : A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

8 : A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

9 : A nurse is preparing to instill ear drops to a 3-year-old child. Which of the following techniques should the nurse use?

10 : A nurse is preparing to administer medications to a client who states, "l don't want to take those drugs." Which of the following actions should the nurse take?

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