Chapter 4-Validating an Documenting Data
79.What are the primary frameworks used in conducting a health assessment? Select all that apply
Functional systems-Head to toe-Body systems
112.While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the
pain relief measures.
100.A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
22.A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
9.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
38.While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the
pain relief measures.
92.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
20.What information concerning a client's respirations should the nurse record after completing a general physical assessment?
rate, rhythm, and depth of respirations taken for a full minute
71.An inexperienced nurse has just performed percussion on a client's chest and detected hyper
resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?-Verify the data by having another nurse come in to perform the percussion.
4.During the chest auscultation portion of a general survey, a 31
year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?-"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
44.During the chest auscultation portion of a general survey, a 31
year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?-"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
93.During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance?
Facility level
96.What are the primary frameworks used in conducting a health assessment? Select all that apply
Head to toe- Functional systems-Body systems
98.How does the client's medical record affect financial reimbursement? (select all that apply.)
Insurance companies audit client records to ensure that billing is accurate
47.The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
36.The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure
115.A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the client record simultaneously.
110.The nurse is admitting a client to a medical unit. The client is concerned that all of his private health information is on the computer and an error may occur. What is the most appropriate response of the nurse?
"The electronic medical record is one of the tools we use to keep you safe."
90.A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?
A record supplied by a physician in which diagnoses and prescribed treatments are recorded
11.A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?
A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight
105.A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data?
Compare objective findings with subjective findings.
107.A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
19.Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
30.The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
114.During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance?
Facility level
23.When charting by exception is used in a health care agency, the most important aspect of this method is what?
Identifying the standards and norms for the institution
102.How does computerized documentation enhance communication? (Select all that apply.)
It is legible and time dated-It permits multiple simultaneous users- It increases compliance
109.The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?
Leave the room to obtain another armband for the client.
104.A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?
Narrative charting
13.A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?
Specialty area assessment form
51.A nurse is documenting a skin condition that she has observed while examining a client. Which of the following descriptions would be most appropriate to include in the client's chart?
Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right anterior forearm
25.To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
3.To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
33.After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
101.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
106.A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data.
111.The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes.
113.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
108.An inexperienced nurse has just performed percussion on a client's chest and detected hyper
resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?-Verify the data by having another nurse come in to perform the percussion.
103.The nurses who provide care in a large, long
term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?-Vulnerability to legal liability since the nurse's safe, routine care is not recorded.
45.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
64.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
83.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
80.The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?
Assessment data in the medical record
99.The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?
Assessment data in the medical record
31.Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
48.Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
66.Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
6.A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a client's record?
"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."
60.The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data?
"I have pain across my entire forehead."
28.Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
37.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
57.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
76.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
91.The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write
"bilateral lung sounds clear."
95.The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply
Appetite good-Right foot swollen-Vital signs normal
14.A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what first nurse reported
82.One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal?
By continual communication with all members of the health care team
54.A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
73.A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
2.The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
Client safety increases
26.Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
16.Which assessment is most likely performed when a client is admitted to the hospital?
Comprehensive
70.A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
89.A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
42.A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing
63.A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing
53.A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error?
Draw a line through the error, write "error," and initial the entry.
46.The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
7.The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
35.A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
55.A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
74.A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
Legal document of care-Promoting effective communication between caregivers-A method to gather research data-Determining eligibility for reimbursement
78.A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the client record simultaneously.
94.A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?
It allows several health team members to view the client record simultaneously.
10.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.
32.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.
50.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.
27.Examples of objective data include all the following except:
Itchy skin
85.The nurse is reviewing the client's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the client's status?
Progress notes
68.Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?
Meaningful use of electronic health records
87.Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?
Meaningful use of electronic health records
65.The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
86.The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
52.A nurse is currently in the assessment phase of the nursing process with a client. Which pieces of information should the nurse document during this phase? Select all that apply.
Nursing history-Information provided by the client-Physical assessment data
84.A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis?
Progress notes
34.A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
72.A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
61.The medical record serves many purposes. What are they? (Select all that apply.)
Research-Framework for medical information-Care planning-Means for financial reimbursement
15.The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
29.A nursing instructor is teaching how to document vital signs on the chart. The student demonstrates understanding of accurate documentation when she makes the following recording
T 37C, P 80, R 12 breaths/min, BP 118/62 mm Hg.
5.The nurse knows that when documenting on a client's chart, assessment information must be concise and accurate, and that all descriptions must be as precise as possible. An example of the best documentation of a wound is:
The abdominal wound measures 6 cm by 9 cm with a 1-cm depth.
12.A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.
The client's weight-lifting routineThe client's occupationThe client's family history of cancer
41.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
62.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
81.A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
1.A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
69.A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data.
88.A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?
Use phrases instead of sentences to record data.
21.When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply
What the nurse observed -What the nurse palpated -What the nurse heard
97.When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply
What the nurse palpated-What the nurse observed- What the nurse heard
75.The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes
56.The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes.
8.A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well
defined standards of practice. Which of the following best defines this type of charting?-Charting by exception
24.A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
details are often missing
17.If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing.
39.One disadvantage of the open
ended assessment form is that it-requires a lot of time to complete.
58.One disadvantage of the open
ended assessment form is that it-requires a lot of time to complete.
43.A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):
organized-accurate-concise-timely-Complete
49.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
67.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
59.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
77.The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
18.The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
40.The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
