chapter 9, 19, 6 study guide 47, 4 exam 4

A nurse has administered six units of insulin to the client as per order. What is the safest documentation of this information?

6 units of insulin administered

A hospital client has expressed dissatisfaction with the quantity and quality of care that the client has been receiving since admission. The client has told the nurse the client would like to read his or her medical record. How should the nurse best respond to the request?

Grant the client access to the health record in accordance with the hospital's policies.

A nurse working in a rural area settting 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 physician's information in the physician's progress notes. The nurse is using which method of documentation?

Source-oriented A source-oriented record is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the Problem, Intervention, Evaluation (PIE) format, and evaluated each shift. Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

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

The nurse documents clients' responses to nursing interventions. Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by the Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health history and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

A recent nursing graduate has begun working at a site where SOAP charting is used for nursing documentation. When completing this form of documentation, the nurse will:

differentiate between subjective assessment data and objective assessment data. The four major components of SOAP charting are subjective data, objective data, analysis of the data, and the plan for care. Subject, object, prognosis, action, and progress are not specific components of SOAP documentation.

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 client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

public health department

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

urine output 100 ml Objective data is collected by the nurse, such as the measurable urine output. Subjective data, such as feeling pain, itchiness, or fatigue, is reported by the client.

At 8:15 pm, a client reports pain and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?

2015 Military time uses a 24-hour time cycle instead of two 12-hour cycles. So 8:15 p.m. is equivalent to 2015.

The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

What is the primary purpose of the client record?

Communication - The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another.

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? Select all that apply.

Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard.

Which charting formats permit documentation on any significant topic, not just client problems?

FOCUS FOCUS charting permits documentation on any significant topic. It is organized around data, action, and response.

The nurse is thinking of a career in informatics. Before applying to a college to undertake the necessary coursework for Information Nurse Specialist, the nurse reviews qualifications for a position as Informatics Nurse (IN), a first step in changing to a career in informatics. Which would be qualifications and responsibilities for a position as an IN? Select all that apply.

Is a superuser Training is primarily on the job Implements an electronic health record (EHR) The IN has experience with implementation of an EHR and is considered a superuser. Training for an IN is usually on the job. The Information Nurse Specialist (INS) has graduate-level education in informatics and is responsible for strategy development, implementation, and maintenance and evaluation of clinical systems.

The nurse gives a change-of-shift report to the oncoming nurse. What vital information does the nurse include in the report? Select all that apply.

Mrs. B. Johnson in Room 564, admitted postoperatively for an open cholecystectomy No new labs have been ordered after surgery Client has a clean and dry abdominal dressing Pain level is currently a 3 following administration of morphine IV Vital information that the nurse would include in a change-of-shift report are the client's name, room number, diagnosis, laboratory data, dressings as part of the physical assessment, and pain/pain management. Information that is not vital includes the client's hobby and dogs at home.

Which abbreviation is correct for use in documentation?

PO signifies by mouth.

To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?

Recommendations

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?

The laboratory assistant can only retrieve patient records but cannot view the details Page 124

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?

those directly involved in the client's care