Chapter 19: Documenting and Reporting (3)

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? pg. 459

"A coronary artery bypass graft will benefit your heart."

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? pg. 463-465

"I will have to review the policy that determines what procedure is in place for client access."

The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse's shift ended. Which information will determine if the nurse is liable? pg. 453-454

Omitting documentation of blood pressure at the end of the shift

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? pg. 583

Refer to the health care provider.

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? pg. 479

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:

Although not written, the nurse must know or question the rationale before performing an action.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? pg. 469

subjectivity

Which principle should guide the nurse's documentation of entries on the client's health care record? pg. 456

Precise measurements should be used rather than approximations.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): pg. 456

legal document.

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse? pg. 457

"I will arrange access for you to review the record after you put your request in writing."

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? pg. 232

SBAR

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. pg. 475

- identifying demographics, including diagnosis - any abnormal occurrences with the client during the shift - current orders

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? pg. 469

It provides quick access to abnormal findings.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? pg. 468

progress notes

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? pg. 475

"It will allow for us to see the client and possibly increase client participation in care."

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? pg. 468

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? pg. 474

Reporting

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? pg. 475

Inform the health care provider that a written order is needed.

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? pg. 468

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? pg. 469

Subjective data should be included when documenting.