class 10 - documenting and reporting

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." "The CABG procedure will help identify nutritional needs." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help increase intestinal motility and prevent constipation."

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

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." "No, the health care provider will not give you access to review the records." "Are you questioning the care of your child?" "Only the client has the right to review the health care records."

"I will arrange access for you to review the record after you put your request in writing."

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? "The hospital owns your records and does not have to allow you access while you are a client here." "I will have to review the policy that determines what procedure is in place for client access." "Let me open up the computer access so that you can see what information is of interest to you." "You may not understand all of the information and it will confuse you so I will help you decipher it all."

"I will have to review the policy that determines what procedure is in place for client access."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? "Let me get that for you." "Only authorized persons are allowed to access client records." "The provider will need to give permission for you to review." "I am sorry I can't access that information."

"Only authorized persons are allowed to access client records."

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use? 0815 0945 1945 2015

2015

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. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record.

Inform the health care provider that a written order is needed.

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 documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.

It provides quick access to abnormal findings.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Recording nursing interventions Identifying nursing diagnoses or clients' needs Omitting clients' responses to nursing interventions Documenting clients' health histories and discharge planning

Omitting clients' responses to nursing interventions

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Only use abbreviations approved by the facility. Avoid using client names in EHR entries Use PIE charting, even if it is not the institution's specified charting method. Only document changes in the client's status.

Only use abbreviations approved by the facility.

At change of shirt, the nurse is presenting information about a client to a colleague that is coming on shift. The nurse is performing what nursing action? Dialogue Documentation Reporting Verification

Reporting

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 National League for Nursing American Nurses Association Occupational Health and Safety Administration (OSHA)

TJC

Which finding from a nursing audit reflects high standards for client safety and institutional health care? The nurse records inappropriate nursing interventions. The nurse fails to identify the nursing diagnoses or clients' needs. The nurse documents clients' responses to nursing interventions. The nurse fails to adequately complete data on clients' health histories and discharge planning.

The nurse documents clients' responses to nursing interventions.

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? identifying risks and ensuring future safety for clients gauging the nurse's professional performance over time protecting the nurse and the hospital from litigation following up the incident with other members of the care team

identifying risks and ensuring future safety for clients

Besides being an instrument of continuous client care, the client's health care record also serves as a(an): assessment tool. legal document. Kardex. incident report.

legal document.

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

subjectivity

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis? the client's family the public health department Health Canada the client's employer

the public health department

Which information should the nurse include in a client's plan of care? Select all that apply. The client's problems, goals, and nursing orders Routine care, such as the client's bath and mouth care The client's level of activity and current medical orders The client care assignment of the nursing and support staff The minutes of the most current team conference meetings

The client's problems, goals, and nursing orders Routine care, such as the client's bath and mouth care The client's level of activity and current medical orders

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? data base problem list plan of care progress notes

progress notes

Which statement is not true regarding a medication administration record (MAR)? If the client declines the dose, the nurse does not have to document this on the MAR. The MAR distinguishes between routine and "as needed" medications. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.

If the client declines the dose, the nurse does not have to document this on the MAR.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: have the right to copy their health records. need to obtain legal representation to update their health records. can be punished for violating guidelines. are required to obtain health record information through their insurance company.

have the right to copy their health records.

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 gives clients the right to withhold the release of their information to anyone. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care.

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 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 is receiving sufficient relief from pain medication, stating no pain in either knee. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client reports that on a scale of 0 to 10, the current pain is a 3. The client appears to have a low tolerance for pain and frequently reports intense pain.

The client reports that on a scale of 0 to 10, the current pain is a 3.

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. what the client watched on television during the shift what time the nurse will return for the next shift any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

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 declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? those directly involved in the client's care any family member of the client close friends of the client health care professionals of the facility

those directly involved in the client's care