Ch.17

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry?

"Client complaining of abdominal pain rated at 8/10."

Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting?

"If I make an error, I draw a single line through it and put my initials by it."

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse?

"It's hard to be in bed and ask for help. You ring for a nurse who never seems to help."

An elderly client is advised to undergo a 12-lead ECG assessment. The client seems to be anxious because this is the first time he is undergoing such a procedure. What explanation should the nurse provide to the client?

"The ECG electrodes are painless and will record electrical activity of the heart."

The wife of a client who is terminally ill expresses to the nurse that she is unable to see her husband die and she may not come to the health care facility anymore. What should the nurse's response to her be?

"You have been coming here every day; are you taking some time for yourself?"

A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?

A graphic sheet

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?

Charting by exception

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation?

Cross out the incorrect statement with a single line.

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 her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

Identifying risks and ensuring future safety for clients

The nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the nursing assistant failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. Which of the following would be most appropriate for the nurse to do?

Include time and date of the incident on the form

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

Intervention carried out

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

It provides quick access to abnormal findings.

What organization audits charts regularly?

Joint Commission on Accreditation of Healthcare Organizations

In many institutions, which of the following telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?

Orders for antibiotics

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

What dual purpose does an audit serve?

Quality assurance and reimbursement

How can a nurse obtain additional information about a client?

Read the client's history and assessment.

A nurse is working as a case manager, and in this role she audits charts. Audits of client records are performed primarily for quality assurance and

Reimbursement

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is what? A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Retrieval of information is more efficient.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the healthcare provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the healthcare provider?

SBAR

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?

SOAP charting

Charting in which the nurse writes a progress note that relates to one health problem is a

SOAP note

How can the nurse researcher obtain information from a client record?

Study client records

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?1.

The laboratory assistant can only retrieve medical records but cannot view the details.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

A new graduate is working at her first job. Which of the following statements is most important for the new nurse to follow?

Use abbreviations approved by the facility.

Besides using the medical records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift?

Change of shift reports

A nurse, when documenting the health details of a client in an acute care agency, fills out all the details under assessment, diagnosis, planning, and implementation. What did the nurse miss as per the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards?

Evaluation of outcomes

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Current client assessment

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 refuses. The nurse's refusal is based on the understanding that which of the following people would be entitled to access of the client's records?

Those directly involved in the client's care

A nurse caring for a client with bronchitis and phones the laboratory for the results of the client's sputum culture. Which of the following would be least appropriate to include when communicating with the laboratory?

Time the specimen was ordered

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?

When communicating a patient's change in condition to the patient's physician

The student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it is on the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)?

Epogen 6500 U SQ daily

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

To investigate the quality of care in the agency

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for patients diagnosed with multiple sclerosis, and their families. Providing this information is an example of which of the following?

A referral

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

Ensure that the client's name appears on all pages.

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ...

Avelox (moxifloxacin) 400 mg daily