Prep U Chapter 9
The following information appears on a client's medical record: Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area. When documenting this information using the SOAP method, which part would the nurse document as "S"?
"I have a fair amount of pain in my belly near my incision"
A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an BAR report. Which statement represents the final step in this type of communication?
"I think the client would benefit from intravenous furosemide."
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."
Which are examples of breaches of client confidentiality? Select all that apply.
-A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse updates the employer of a client regarding the client's date of return to work.
Which actions should the nurse take to ensure that client information remains confidential? Select all that apply.
-Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. -Exit the client's room when called on the hospital-issued cell phone about another client on the team. -Verify the number in the fax machine as correct prior to transmission.
The client states, "I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today." The client's arms are folded across his chest. His brow is furrowed, and he will not allow morning vital sign measurements. Which entry should be included in the nurse's charting? Select all that apply.
-arms folded across chest and brow is furrowed -states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today" -will not allow morning vital sign measurements
Which is the proper way to document midnight in a client's record?
0000
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
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 physician wrote in his chart.
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 physician wrote in his chart.
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?
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 documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error?
Create an notation with a correction.
Which practice should the nurse adopt when communicating and documenting electronically?
Include precise measurements in documentation rather than approximations
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.
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 is documenting a progress note that differentiates between assessment findings that the nurse has obtained directly, and data or symptoms that the client desribes, What form of documentation is the nurse writing?
SOAP note
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.
The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?
Suggest to the nurse manager that an in-service on abbreviation use would be helpful.
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?
TJC
Which statement regarding FOCUS charting is most accurate?
The charting focuses on client strengths, problems, or needs.
The nurse is caring for a client on a medical unit that uses focused charting to document client care. Which written statement by the nurse demonstrates the use of focused charting to document the client assessment?
The client rates abdominal pain at 8/10.
Which finding from a nursing audit reflects high standards for client safety and institutional health care?
The nurse documents clients' responses to nursing interventions.
Which finding from a nursing audit reflects high standards for client safety and institutional health care?
The nurse documents clients' responses to nursing interventions.
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.
The nurse documents the following entries in the charts of clients. Which entries are using correct abbreviations? Select all that apply.
Used sliding scale insulin protocol for elevated blood sugar. Administered labetalol for systolic BP that was greater than 160.
Which strategy would provide the most effective form of change of shift report?
Utilizing a reporting form and allowing time for any questions.
What is the primary purpose of the client record?
communication
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
flow sheet
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
have the right to copy their health records.
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.
A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?
nursing care rounds
A nurse at a community-health centre is completing an audit of patient records: The outcomes of this project will serve what purposes?
quality assurance and reimbursement
In SBAR, what does R stand for?
recommendations
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?
subjectivity
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."
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.
During rounds, the nurse finds that a client with paralysis has fallen from the bed because the unlicensed assistive personnel (UAP) failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. What would be most appropriate for the nurse to do?
Include time and date of the incident on the form.
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
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?
Omitting clients' responses to nursing interventions
A nurse organizes client data using the SOAP format. Which information would be recorded under "S" of this acronym?
The client reports pain.
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 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
What situation would permit the nurse to disclose information without the client's approval?
the nurse suspecting that a client is being abused or neglected
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?
urine output 100 ml
