Documentation ch 15 PrepU

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.

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 ml undigested food, antiemetic given, no further vomiting

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? a) "Client is guarding her abdomen and occasionally moaning." b) "Client complaining of abdominal pain rated at 8/10." c) "2 mg Dilaudid PO administered with good effect" d) "Client has a history of recent abdominal pain."

b) "Client complaining of abdominal pain rated at 8/10."

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? a) Multidisciplinary interventions b) Intervention carried out c) Written plan of care d) Client assessment

b) Intervention carried out

What is the primary purpose of an incident report? a) Basis for staff evaluation b) Format for audiotaped report c) Means of identifying risks d) Basis for disciplinary action

c) Means of identifying risks

What information should the nurse document in the medication record when administering a non-narcotic pain medication? (Select all that apply.) a) Reason given b) Dose c) Effectiveness of medication d) Vital signs e) Time

• Time • Dose • Reason given • Effectiveness of medication

It is acceptable for the nurse to accept a verbal order from the physician in which of these situations? a) During a medical emergency b) Immediately prior to discharge c) Upon admission of the patient to the unit d) Prior to the patient leaving the floor for therapy

a) During a medical emergency

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation? a) It records progress under problems, intervention, and evaluation. b) It provides and refers to client's problem by a number. c) It documents assessments on separate forms. d) It provides quick access to abnormal findings.

d) It provides quick access to abnormal findings.

The nurse is finding it difficult to plan and implement care for a patient and decides to have a nursing care conference. What action would the nurse take to facilitate this process? a) The nurse sends or directs someone to take action in a specific nursing care problem. b) The nurse, along with other nurses, visits patients with similar problems individually at each patient's bedside in order to plan nursing care. c) The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. d) The nurse meets with nurses or other health care professionals to discuss some aspect of patient care.

d) The nurse meets with nurses or other health care professionals to discuss some aspect of patient care.

A client with chronic hyperparathyroidism expresses that she is fed up with her diet and can no longer continue with it. What should the nurse's appropriate response to the client be?

"You may be having a difficult time staying on that diet; let's discuss it."

What is the primary purpose of the patient record? a) communication b) advocacy c) research d) education

a) communication

Which of the following data entries follows the recommended guidelines for documenting data? a) "Client complained about the quality of the nursing care provided on previous shift." b) "Following oxygen administration, vital signs returned to baseline." c) "Client's kidneys are producing sufficient amount of measured urine." d) "Client is overwhelmed by the diagnosis of pancreatic cancer."

b) "Following oxygen administration, vital signs returned to baseline."

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours? a) Acuity charting forms b) 24-hour fluid balance record c) A graphic sheet d) Medication record

c) A graphic sheet

A nurse is arranging for home care for patients and reviews the Medicare reimbursement requirements. Which patient meets one of these requirements? a) A patient whose status is stabilized b) A patient whose rehabilitation potential is not good c) A patient who is homebound and needs skilled nursing care d) A patient who is not making progress in expected outcomes of care

c) A patient who is homebound and needs skilled nursing care

A nurse, when documenting the health details of a client in an acute care agency, fills out all the details under assessment, diagnosis, planning, and implementation. What did the nurse miss as per the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards? a) Physician's feedback b) Client's diet chart c) Evaluation of outcomes d) Client's past medical history

c) Evaluation of outcomes

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: a) Using only those abbreviations that are defined in full at another location in the client's chart. b) Ensuring that abbreviations are understandable to clients who may seek access to their health records. c) Using only abbreviations whose meaning is self-evident to an educated health professional. d) Limiting abbreviations to those approved for use by the institution.

d) Limiting abbreviations to those approved for use by the institution.

Which of the following are examples of breaches of client confidentiality? Select all that apply. a) A nurse shares her computer password with a relative of a client. b) A nurse checks the medical record of a client to see who should be called in an emergency. c) A nurse discusses a client with a coworker in the elevator. d) A nurse updates the employer of a client regarding the client's return to work. e) A nurse uses a computer to document a client's response to pain medication.

a) A nurse shares her computer password with a relative of a client. c) A nurse discusses a client with a coworker in the elevator. d) A nurse updates the employer of a client regarding the client's return to work.

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 her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into 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

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? a) FOCUS data, action, and response note b) Narrative notes c) Problem, intervention, and evaluation note d) Charting by exception

d) Charting by exception

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider? a) eMAR b) SOAP c) CBE d) SBAR

d) SBAR

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? a) The plan includes interventions, evaluation, and response. b) Objective data is what the client states about the problem. c) Subjective data should be included when documenting. d) Abnormal laboratory values are common items that are documented.

c) Subjective data should be included when documenting.

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? a) close friends of the client b) any family member of the client c) those directly involved in the client's care d) health care professionals of the facility

c) those directly involved in the client's care

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

d) have the right to copy their health records.

An elderly client is advised to undergo a 12-lead ECG assessment. The client seems to be anxious because this is the first time he is undergoing such a procedure. What explanation should the nurse provide to the client?

"The ECG electrodes are painless and will record electrical activity of the heart."

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

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? a) A client has asked a nurse if he can read the documentation that his physician wrote in his chart. b) A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. c) A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. d) A client who resides in Indiana has required hospitalization during a vacation in Hawaii.

a) A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

The nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report? a) Incident report b) Transfer report c) Telemedicine report d) Nurse's shift report

a) Incident report

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? a) SOAP charting b) Narrative charting c) PIE charting d) Focus charting

a) SOAP charting

Which statement regarding focus charting is most accurate? a) The charting focuses on client strengths, problems, or needs. b) Problem, Intervention, Evaluation (PIE) charting is used with focused charting. c) The charting focuses on the injury or illness only. d) Each note should include each section of the Data, Action, Response (DAR) format of charting.

a) The charting focuses on client strengths, problems, or needs.

A nurse uses the computer to access health records of the clients. What care should the nurse take when using a computer to access health records? a) The password and access number should be kept secret and changed regularly. b) The password and access number should be shared only with the auditors. c) The password and access number should be shared only with the physician. d) The password and access number should be shared only with the client.

a) The password and access number should be kept secret and changed regularly.

What is the primary purpose of focus charting? a) patient concerns b) nursing diagnoses c) medical problems d) expected outcomes

a) patient concerns

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the nursing assistant 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? a) Mention the name of nursing assistant in client records. b) Include time and date of the incident on the form. c) Attach a copy of the incident report to the client's records. d) Highlight the incident in the client's records as involving an error.

b) Include time and date of the incident on the form.

Which example may illustrate a breach of confidentiality and security of client information? a) The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. b) The nurse provides information over the phone to the client's family member who lives in a neighboring state. c) The nurse accesses client information on the computer at the nurse's station, then logs off before answering a client's call bell. d) The nurse provides information to a professional caregiver involved in the care of the client.

b) The nurse provides information over the phone to the client's family member who lives in a neighboring state.

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"? a) Client lying on side with legs drawn up b) Abdomen distended c) "I have a fair amount of pain in my belly near my incision" d) Administer oxycodone 5 mg as ordered

c) "I have a fair amount of pain in my belly near my incision"

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 her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a) Gauging the nurse's professional performance over time b) Protecting the nurse and the hospital from litigation c) Identifying risks and ensuring future safety for clients d) Following up the incident with other members of the care team

c) Identifying risks and ensuring future safety for clients

A nurse has a two-way video communication with the specialist involved in the care of a patient in a long-term care facility. This is an example of what nursing informatics technology? a) Data aggregation technology b) Population health management technology c) Telemedicine and mobile technology d) Patient engagement technology

c) Telemedicine and mobile technology

What is the primary purpose of the patient record? a) research b) education c) communication d) advocacy

c) communication

The wife of a client who is terminally ill expresses to the nurse that she is unable to see her husband die and she may not come to the health care facility anymore. What should the nurse's response to her be? a) "You are right; after all, your husband knows that you love him. We will take care of him." b) "I think at this stage of the disease, you should focus on your husband and not yourself." c) "Your husband would come to know that you are not here, and you would feel guilty." d) "You have been coming here every day; are you taking some time for yourself?"

d) "You have been coming here every day; are you taking some time for yourself?"

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for patients diagnosed with multiple sclerosis, and their families. Providing this information is an example of which of the following? a) A consultation b) Reporting c) Conferring d) A referral

d) A referral

A nursing supervisor overhears one of the staff nurses say, "I only document vital signs when they are out of the normal range." What action by the nursing supervisor should be implemented first? a) Review the staff nurses' documentation on assigned clients. b) Obtain copies of the hospital's policy on documentation and post it on the unit. c) Develop an inservice, highlighting the legal aspects of documentation along with hospital and accreditation requirements. d) Discuss with the staff nurse that the recording of all client data, even when normal, is important in providing and evaluating care.

d) Discuss with the staff nurse that the recording of all client data, even when normal, is important in providing and evaluating care.

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?1. a) The laboratory assistant is trying to view archived data. b) The laboratory assistant does not have the correct password. c) The laboratory assistant does not have the correct access number. d) The laboratory assistant can only retrieve medical records but cannot view the details.

d) The laboratory assistant can only retrieve medical records but cannot view the details.