CHAPTER 19 documenting / Reporting

1 Unit of glucose

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information

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?

Refer to the health care provider.

The following statement is documented in a client's health record: "Patient 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.

urine output 100 ml

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

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

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?

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

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?

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

The nurse documents clients' responses to nursing interventions.

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

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

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

Charting by exception (CBE)

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.