chapter 20

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

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

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

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?

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

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?

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

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse?

"Legal policy requires nursing practice to be permanently integrated into the client record."

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 nurse is caring for a postoperative client who is experiencing hypotension. When contacting the client's health care provider, the nurse will include which statement in the SBAR report? Select all that apply.

"The client demonstrates additional signs of hypovolemia including slow capillary refill." The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." " The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery."

Which is the proper way to document midnight in a client's record?

0000

Which clinical situation 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 health care provider wrote in his chart.

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?

A variance

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply.

After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse reads back the health care provider's new orders at the conclusion of the call.

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 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.

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate?

Assess the triggers from the data.

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

Which note includes all elements of a SOAP note?

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

Which statement about client records and documentation is correct?

Communication is the primary purpose of client records.

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard

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

Documentation

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"?

FOCUS

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

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

Incident report

Which practice should the nurse adopt when commmunicating and documenting electronically?

Include precise measurements in documentation rather than approximations.

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.

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?

It provides quick access to abnormal findings.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records

A nurse is working at a first job. When completing client documentation, the nurse should perform which action?

Only use abbreviations approved by the facility.

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.

A nurse manager of a health care provider's office is responsible for obtaining signed authorizations for releasing client information to third parties. In which situations would it not be necessary for the nurse to obtain an authorization from the client? Select all that apply

Reporting the incidence of an infectious disease to Centers for Disease Control and Prevention Releasing a medical record to the court when a nurse is being sued for negligence Facilitating organ donation of a deceased client Providing statistics related to the use of a dangerous piece of equipment

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?

Review the hospital's process for allowing clients to view their health care records.

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

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

Subjective data should be included when documenting.

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to?

The Joint Commission

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 following statement is documented in a client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply.

The content is not in accordance with professional standards. There are lines between the entries. Dates and times of entries are omitted.

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?

The lower extremities

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider?

The nurse can accept verbal orders to provide immediate care and record once the client is stable.

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation?

The nurse could be fined or even go to jail for violating HIPAA.

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

The nurse documents clients' responses to nursing interventions.

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.

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.

Which is not a purpose of the client care record?

To serve as a contract with the client

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?

Translators may need additional explanations of medical terms.

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?"

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing 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.

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.

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

A nurse is working as part of a team that has been asked to address the issue of confidentiality and documentation of client health information electronically. Which activity(ies) would the team suggest to help ensure confidentiality? Select all that apply.

having each person responsible for documenting in the electronic health record not share his or her password placing computer screens in locations that face away from any public areas such as hallways ensuring that individuals log off a computer terminal when documentation is completed

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

legal document.

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.

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?

omitting documentation of blood pressure at the end of the shift

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?

progress notes

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml

The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate?

"Myocardial infarction."

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

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

Documentation

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply.

Documenting entries that are up to date and comprehensive Recording the date and time of all entries Using approved agency abbreviations

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply.

Readable Thoughtful Timely Clear, concise, and complete

At change of shift, the nurse is presenting information about a client to a colleague that is coming on shift. The nurse is performing what nursing action?

reporting

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?

those directly involved in the client's care

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

subjectivity

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