Fun ch. 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 nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

In SBAR, what does R stand for?

Recommendations

What ensures continuity of care?

communication

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

0000

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

interpretation of data.

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

urine output 100 ml

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

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

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?

Client's record and occurrence report

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

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

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."

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.

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.

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

Submitting a written notice to all clients identifying the uses and disclosures of their health information

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

Which statement regarding FOCUS charting is most accurate?

The charting focuses on client strengths, problems, or needs.

A health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. In what scenario is this most important?

The client has had a sudden change in status needing immediate attention.

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.

The nurse is reviewing a client's chart. When reading the history, physical, and health care provider progress notes, the nurse anticipates finding which information?

The health care provider's assessment and treatment

Which is not a purpose of the client care record?

To serve as a contract with the client

Which is the primary purpose of client records?

communication

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

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 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 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 unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it."

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development?

"The care plan is required for every client by The Joint Commission."

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift?

"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?

"The clients' medical records are an obstruction to research and education."

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

legal document.

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

reimbursement.

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

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

subjectivity

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.

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

-Reviewing the agency's list of approved abbreviations -Locating clients' files within an electronic health record system -Identifying the form appropriate to be used for documenting

The nurse documents a progress note in the wrong client's electronic health record (EHR). Which action would the nurse take once realizing the error?

Create an notation with a correction.

HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply.

-A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low -The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. -The nurse calls out names in the waiting room, but does not disclose the reason for the client visit.

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.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

-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

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.

-Showing the provider the trends from baseline to present in blood pressure -Informing the provider of the client's present heart rate of 116 beats/min -Faxing the results of blood chemistry levels to the provider's office

The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include? Select all that apply.

-The client's blood pressure trend over the past 24 hours. -The primary reason the client was admitted to the hospital. -Objective and subjective data from the most recent assessment. -An explanation of what is needed to improve the hypotensive state.

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

What does the nurse recognize as purposes of the electronic health record? Select all that apply.

-documenting continuity of care -qualifying health care providers for government funds -ensuring client safety -facilitating health education and research

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

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

1. "I don't feel well. I've been urinating often, and it burns when I urinate." 2. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3. Fever, possible urinary tract infection 4. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth

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.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?

Attach a copy of the incident report to the chart

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.

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

Documentation

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 communicating 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.

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method

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 working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the health care provider's information in the health care provider's progress notes. The nurse is using which method of documentation?

Source-oriented

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

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

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.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?

Use minimum disclosure policy to release the information.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?

Write a narrative note in the designated nursing section.

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