Chapter 4: Validating and Documenting Data Prep U

One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it

may be easily used by different levels of caregivers, which enhances communication

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

The nurse is reviewing the client's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)

-Bowel sounds are hyperactive in all 4 quadrants -Coarse rhonchi noted throughout lung fields -Left dorsalis pedis pulse weaker than right

The nurse understands that information documented in the client's medical record provides a foundation for care providers to do what? Select all that apply.

-Develop a plan of care -Coordinate care -Communicate care

Which strategy reduces documentation errors? Select all that apply.

-Document client information immediately -Designate a person to document during emergencies -Organize client data logically, using a timed sequence

How does computerized documentation enhance communication? (Select all that apply.)

-It is legible and time dated -It permits multiple simultaneous users -it increases compliance

After reviewing several client records, the nurse manager determines that documentation guidelines need to be reviewed with staff when which of the following is observed in the client records? Select all that apply.

-Liquid paper was used to correct an error -An entry was completely marked out by a black marker

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 occupation -The client's family history of cancer -The client's weight-lifting routine

After performing a comprehensive assessment on a client. The nurse charts the following findings. Which chart entry meets documentation guidelines? Select all that apply.

-skin pink with consistent pigmentation -voiding clear yellow urine (urine output 3,300 mL/day)

The nurse performs a comprehensive assessment on a client with high blood pressure. The nurse uses the SBAR communication tool to communicate the findings to the health care provider. Which statement is accurate?

65-year-old male has high blood pressure 180/95 mm Hg, headache, and blurred vision; past medical history: smoker, emphysema, coronary artery disease, no known drug allergies. May I have an order for a blood pressure medication?

A nurse manager is making rounds in the hospital unit. Which of the following actions would require the nurse manager to intervene if observed?

A nurse charts "liver palpation normal."

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

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

A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?

Decreased range of motion in right shoulder

A nurse is using a minimum data set to document findings following the assessment of a client. This nurse is most likely providing care in which setting?

Long-term care facility

A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use?

Nursing minimum data set

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, and time?

Nursing minimum data set

When a nurse works in a health care agency that charts by exception (CBE), the nurse knows that the client assessment is structured by what?

Standardized norms

When a client reports having had surgery, yet physical examination reveals a 10-cm abdominal scar the nurse needs to:

Validate the data