A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
"Blood not drawn because tests are no longer desired by patient."
"Refuses to have blood drawn; says tests are 'useless. Doctor notified."
"Doctor notified of failure to draw ordered blood work."
"Refuses to have blood drawn. Doctor notified."
The Correct Answer is B
A. "Blood not drawn because tests are no longer desired by patient."
This statement is vague and lacks specific details regarding the patient's exact refusal and the communication with the doctor.
B. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
This response documents the patient's refusal with their exact words ("useless") and also notes that the doctor has been informed, which is essential for clear, complete documentation.
C. "Doctor notified of failure to draw ordered blood work."
This documentation lacks the reason for the blood draw failure (patient refusal) and omits the patient’s specific wording.
D. "Refuses to have blood drawn. Doctor notified."
Although this documents the refusal and the doctor’s notification, it omits the patient’s exact words, which can provide additional context for the healthcare team.
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Correct Answer is B
Explanation
A. Saving the extra time it would take to mail the information.
The purpose of asking the patient to repeat information is not about saving time but to ensure accurate understanding.
B. Verifying that the patient understands the information.
Asking the patient to repeat the information confirms that they understood it correctly, which is essential in promoting effective communication and preventing misunderstandings.
C. Acting in a cautious way to avoid charges of negligence. While caution is involved, the primary purpose is to ensure understanding rather than legal protection.
D. Testing the patient's intelligence and memory.
This is not a test of intelligence or memory but rather a verification of understanding.
Correct Answer is B
Explanation
A. is packing belongings in preparation for discharge. Although discharge is an appropriate time for patient education, it may be too late to introduce complex information that requires practice or understanding. Teaching moments often occur earlier in the care process.
B. says, "How will I remember all the things about my new diet?" This is an ideal teaching moment as the patient is expressing concern and showing readiness to learn about the diet. The nurse can use this moment to provide guidance on strategies to remember dietary instructions.
C. has just returned from surgery for a deviated septum. Immediately post-surgery, the patient may be under the influence of anesthesia or pain medication, limiting their ability to absorb information. Teaching at this time may not be effective.
D. has just been told of the malignancy of his tumor. Right after receiving bad news, patients may experience shock, grief, or distress, making it difficult for them to process additional information. This may not be the right time for education.