CH. 20 Documentation Prep U

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? A; "A coronary artery bypass graft will benefit your heart." B; "The CABG procedure will help identify nutritional needs." C; "A complete ablation of the biliary growth will decrease liver inflammation." D; "The CABG procedure will help increase intestinal motility and prevent constipation."

A

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? A; those directly involved in the client's care B; any family member of the client C; close friends of the client D; health care professionals of the facility

A

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? A:identifying risks and ensuring future safety for clients B;gauging the nurse's professional performance over time C;protecting the nurse and the hospital from litigation D;following up the incident with other members of the care team

A

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? A; Inform the health care provider that a written order is needed. B; Write the order in the client's record. C; Call the pharmacy to have the order entered in the electronic record. D; Add the new order to the medication administration record

A

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? A; subjectivity B; objectivity C; organization D; reimbursement

A

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? A; "The care plan is required for every client by The Joint Commission." B; "The care plan is the only way for nurses to document what they do." C; "The care plan provides additional documentation about the work of the nurse." D; "The care plan shows the medical diagnosis for the client."

A

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? A; Ask the client if information can be given to the parent. B; Provide the information to the parent. C; Explain the reasons for the hospitalization, but give no further information. D; Take the parent to the client's room and have the client give the requested information.

A

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A; limiting abbreviations to those approved for use by the institution. B; using only abbreviations whose meaning is self-evident to an educated health professional. C; ensuring that abbreviations are understandable to clients who may seek access to their health records. D; using only those abbreviations that are defined in full at another location in the client's chart.

A

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A; A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart. B; A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. C; A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. D; A client who resides in Indiana has required hospitalization during a vacation in Hawaii.

A

Which is the proper way to document midnight in a client's record? A; 0000 B; 2401 C; 1200 D; 1201

A

Which statement is not true regarding a medication administration record (MAR)? A; If the client declines the dose, the nurse does not have to document this on the MAR. B; The MAR distinguishes between routine and "as needed" medications. C; The MAR identifies routine times for medication administration. D; After using an electronic MAR, the nurse should log off.

A

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? A; "Let me get that for you." B; "Only authorized persons are allowed to access client records." C; "The provider will need to give permission for you to review." D; "I am sorry I can't access that information."

B

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: A; factual statement. B; interpretation of data. C; important information. D; relevant data.

B

Which flow sheet provides the health care provider with information on an ongoing record of fluid loss? A; Vital signs graphic sheet B; Intake and output graphic sheet D; Critical care flow sheet E; Health assessment flow sheet

B

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? A; "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." B; "I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." C; "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." D; "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

B

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? A; The client is receiving sufficient relief from pain medication, stating no pain in either knee. B; The client appears comfortable and is resting adequately and appears to not be in acute distress. C; The client reports that on a scale of 0 to 10, the current pain is a 3. D; The client appears to have a low tolerance for pain and frequently reports intense pain.

C

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. A: what the client watched on television during the shift B: what time the nurse will return for the next shift C: any abnormal occurrences with the client during the shift D: identifying demographics, including diagnosis E: current orders

C,D,E

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? A; It documents assessments on separate forms. B; It records progress under problems, intervention, and evaluation. C; It provides and refers to a client's problem by a number. D; It provides quick access to abnormal findings.

D

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? D; Review the hospital's process for allowing clients to view their health care records. A; Access the health care record at the bedside and show the client how to navigate the electronic health record. B; Discuss how the hospital can be fined for allowing clients to view their health care records. C; Explain that only a paper copy of the health care record can be viewed by the client.

D

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting? A; Ensure that the client's name appears on all pages. B; Leave spaces between entries and signature. C; Use abbreviations wherever possible. D; Record all facts and subjective interpretations.

E