chap 19 ML3

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records." The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

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?

Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings?

Refer to the health care provider. Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative. The nurse would refer the client to a health care provider for treatment of depression. Calling the health department or cleaning up the house will not help with the client's depression. Moving the client to an assisted living facility may not be necessary if the client receives treatment for the depression.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

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 nurse implementing?

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their competency. Psychomotor skills are skills that require physical actions and muscular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.

Which principle should guide the nurse's documentation of entries on the client's health care record?

Precise measurements should be used rather than approximations Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care. A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

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

a referral. Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

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?

identifying risks and ensuring future safety for clients Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data. A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?

"I will have to review the policy that determines what procedure is in place for client access." Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?" SBAR is an acronym for Situation, Background, Assessment, Recommendation. Situation is what the nurse describes, the current situation. Background is the pertinent information regarding the current situation. Assessment is objective information that supports the situation. Recommendation is what the nurse recommends to the health care provider. In this case, the Recommendation is the nurse asking the provider to prescribe a complete blood count and culture. "I am concerned that the client might be exhibiting sepsis" is a situation statement. "The client's temperature has been 102°F (38.9°C) for the last 6 hours" is the assessment of the client supporting the situation. The client being admitted today with a urinary tract infection is Background.

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting client care on the client record The client record is the only permanent legal document that details the nurse's interactions with the client and is the nurse's best defense if a client or client surrogate alleges nursing negligence. As the question is written, the only answer that addresses the situation is accurate documentation of the event in the client's record. Notifying the nursing team of the client's condition is important, but not the correct answer for the question. Client data should be correctly documented on the flow sheet, but this is not the correct answer in this case. The medication record should be accurate, but this is not the best answer.

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?

Ask the client if information can be given to the parent. No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

Which organization audits charts regularly?

The Joint Commission The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .

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?

The client reports that on a scale of 0 to 10, the current pain is a 3. The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions. Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution. In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.