FN - Unit 2 - Chapter 20: Documenting and Reporting

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate? Assess the triggers from the data. Document the findings on an occurrence report. Provide a comprehensive written report to the client ombudsperson. Repeat the minimum data set in 2 weeks.

Assess the triggers from the data. Once the minimum data set is complete, it will identify elements or triggers for issues that the resident either has or is at risk for developing. The information should not be documented on an occurrence report, as it is not is a comprehensive written report required to be sent. There is no need to complete the minimum data set in 2 weeks unless the resident has a significant change in condition.

Which charting format permits documentation on any significant topic, not just client problems? CBE SOAP PIE FOCUS

FOCUS FOCUS charting permits documentation on any significant topic. It is organized around data, action, and response. Each of the remaining responses center their documentation on the identification of a problem.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"? PIE FOCUS Narrative Exception

FOCUS The nurse used FOCUS charting, as it gives priority attention to the client's current or changed behavior. PIE charting occurs when the nurse records the client's progress under the headings of problem, intervention, and evaluation. Narrative charting content resembles a log or journal entry. Charting by exception is charting only abnormal assessment findings that deviate from a standard norm. Therefore, this nurse is not demonstrating PIE, narrative, or exception charting.

The nurse is preparing to call a health care provider to report a significant decrease in a client's oxygen saturation level. What action should the nurse take first? Obtain all needed information to give report. Document all findings in the electronic health record. Report the change to the health care provider using ISBAR. Request another nurse stay with the client while the report is called.

Obtain all needed information to give report. The nurse should obtain all needed information first before calling the health care provider, and use the ISBAR format. The nurse will need to document all the findings in the client's record, but should contact the health care provider before documenting due to the significant change in oxygen levels. Asking another nurse to stay with the client is appropriate, but only after all information is gathered.

In SBAR, what does R stand for? Reinforcing data Response Recommendations Report

Recommendations SBAR stands for situation, background, assessment, and recommendations. The other responses are incorrect.

The nurse is documenting a progress note that relates to a client's health problem. What form of documentation is the nurse writing? PIE note flow sheet narrative note SOAP note

SOAP note SOAP note is a progress note that relates to only one health problem.

Which is the proper way to document midnight in a client's record? 0000 2401 1200 1201

0000 0000 is the military time for midnight and is correct. The other military times are incorrect since 2401 is 1 minute past midnight, 1200 is noon, and 1201 is 1 minute past noon.

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? Client's record and occurrence report Occurrence report and critical pathway Critical pathway and care plan Care plan and client's record

Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

Which statement about client records and documentation is correct? Communication is the primary purpose of client records. Clients should keep the original record at home in a fireproof safe. Nurses should not document progress notes in a client's record. Health care providers will not review nurses' documentation in the client's record.

Communication is the primary purpose of client records. Communication is the primary purpose of client records. Original records are kept by the facility, not the client. Nurses should document key information in the client record, and health care providers review nursing documentation to help make clinical decisions.

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. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply. Readable Thoughtful Timely Clear, concise, and complete Accurate, relevant, and lengthy Retrievable on a temporary basis

Readable Thoughtful Timely Clear, concise, and complete Characteristics of effective documentation include accessible, accurate, relevant, consistent, auditable, clear, concise (not lengthy), complete, legible/readable, thoughtful, timely, contemporaneous, sequential, and retrievable on a permanent (not temporary) basis.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? Remind the UAP about the client's right to privacy. Report the UAP to the nurse manager. Notify the client relations department about the breach of privacy. Document the UAP's conversation.

Remind the UAP about the client's right to privacy. The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediately protect the client's privacy.

Which information would the nurse be unable to locate in the client care summary or Kardex? Code status Respiratory assessment Activity status IV therapy

Respiratory assessment Information commonly found in a the client care summary or Kardex includes demographic data, code status, safety precautions, basic care needs (such as activity status or diet), and treatment (such as vital sign schedule, IV therapy, and diagnostic or laboratory tests). An assessment would be located on a flow sheet or within the client's medical record.

Which are purposes of documentation in health care records? Select all that apply. To facilitate quality To serve as a financial record To support decision analysis To assist with clinical research To provide personal communication to the family

To facilitate quality To serve as a financial record To support decision analysis To assist with clinical research Documentation provides data to facilitate quality, serve as a financial record, assist with clinical research, and support decision analysis. Documentation does not serve to provide personal communication to the family.

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? Do not release any information to the insurance company. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client. Release the full medical record to expedite payment.

Use minimum disclosure policy to release the information. The nurse should use minimum disclosure policy to release the information, as per HIPAA regulations. It is inappropriate to not release any information to the insurance company, to refer the insurance agent directly to the client, and to release the full medical record to expedite payment.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? SOAP narrative focus charting by exception

charting by exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

What ensures continuity of care? reassessment critical thinking communication integration

communication Communication ensures continuity of care and provides essential data for revision of. or continuation of care. The acts of reassessment, critical thinking, and integration do not contribute directly to continuity of care.

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and: reimbursement. staff development. research. change of mechanisms.

reimbursement. Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits do not play a role in staff development, research, or change of mechanisms within a system.

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 Quoting what the client is saying helps in the documentation of subjective data. Objective data are assessment data that may be directly observed by the nurse such as blood pressure. Organization is the structure of the documentation and does not relate to subjective data. Reimbursement is a distractor that doesn't relate to assessment data.

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 In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

The nurse is reviewing a client's chart. When reading the history, physical, and health care provider progress notes, the nurse anticipates finding which information? The health care provider's assessment and treatment Results of laboratory and diagnostic studies Nursing documentation and plan of care Information from other members of the health care team

The health care provider's assessment and treatment The medical history, physical examination, and progress notes record the findings of health care providers as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment. The laboratory results will be in a different section of the health record and not typically in the medical history and treatment plan. Nursing documentation will be in the nursing section. Information from the other members of the health care team is found in the progress notes.

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

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A never event A variance An audit A sentinel event

A variance This scenario reflects a variance in care. A variance occurs when the client does not proceed along a clinical pathway as planned. A never event is an error that occurred that should not have. An audit is an evaluation of care that has been performed and documentation that has been made. A sentinel event is a catastrophic event with a client that can cause loss of life or limb or other serious injury to the client.

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. The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

Which is true of collaborative pathways? Are also called critical pathways or care maps Focus on the client's problems, strengths, and needs Incorporate the care plan into the progress notes Only allow recording of significant findings in the notes

Are also called critical pathways or care maps Collaborative pathways—also called critical pathways or care maps—are used in the case management model. The collaborative pathway specifies the care plan linked to expected outcomes along a timeline. With PIE charting, the care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). With focus charting, a focus column is used that incorporates many aspects of a client and client care. The focus may be a client strength, problem, or need. Charting by exception 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.

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? Call the health department. Clean up the house. Move the client to an assisted living facility. Refer to the health care provider.

Refer to the health care provider. Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative. The nurse would refer the client to a health care provider for treatment of depression. Calling the health department or cleaning up the house will not help with the client's depression. Moving the client to an assisted living facility may not be necessary if the client receives treatment for the depression.

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse likely document the results? progress note admission nursing assessment graphic sheet medical record

graphic sheet The graphic sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all of the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few.The admission nursing assessment records the findings of the nursing history and physical assessment upon admission.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: a referral. a consultation. conferring. reporting.

a referral. Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? "Any information that can identify a person is considered a breach of client privacy." "You may continue to post about a client, as long as you do not use the client's name." "All aspects of clinical practice are confidential and should not be discussed." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

"Any information that can identify a person is considered a breach of client privacy." Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "It seems like this client has fluid volume overload." "I think the client would benefit from intravenous furosemide."

"I think the client would benefit from intravenous furosemide." Situation, background, assessment, and recommendations (SBAR) provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (situation) and B (background) provide objective data, whereas the A (assessment) and R (recommendations) allow for presentation of subjective information. Calling to report dyspnea and crackles occurs as the nurse describes the situation. Providing the medical history occurs as the nurse offers important background information. Stating that the client has fluid volume overload is the assessment of the nurse. Stating that the nurse thinks the client would benefit from intravenous furosemide is the nurse's recommendation.

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best? "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them." "Vital signs do not need to be recorded unless they are abnormal." "The UAP logs in under my name and documents the vital signs." "The UAP is able to log in and enter the information so all members of the health care team can see it."

"The UAP is able to log in and enter the information so all members of the health care team can see it." Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? "The benefit of CBE is less time needed on computer charting." "The benefit of CBE is that it demonstrates whether high-quality care is given." "CBE is the best way to protect against lawsuits." "CBE is a relatively new format of documentation in electronic health records."

"The benefit of CBE is less time needed on computer charting." One of the benefits of CBE is less time needed for documentation. CBE does not always support high-quality care and is not the best way to protect against lawsuits since not all data are documented. CBE is not a new format for documentation.

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

1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records? "The clients' medical records provide data for legal evidence." "I can share the clients' medical records with the health care team." "The clients' medical records are an obstruction to research and education." "The clients' health records should be used to promote reimbursement from insurance companies"

"The clients' medical records are an obstruction to research and education." The clients' medical records are good sources of data for research and education, and, therefore, it is incorrect to say that they are an obstruction. The other statements do not need correction.

The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method? 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours 4/10 pain on pain scale, epigastric pain; with reports of nausea NPO, 4/10 pain, epigastric pain, nausea 4/10 pain with nausea; on IV fluids

4/10 pain on pain scale, epigastric pain; with reports of nausea Charting by exception charts only that which falls outside the standard of care and norms. 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours is incorrect because the IV fluids and morphine are expected to occur. NPO, 4/10 pain, epigastric pain, nausea is incorrect because NPO is expected. 4/10 pain with nausea; on IV fluids is incorrect because IV fluids are expected.

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. A client's diagnosis linked to a disease outbreak A client's Social Security number Information about a client's past health conditions A client's address A deceased client's history for organ donation

A client's Social Security number Information about a client's past health conditions A client's address Client information that is considered confidential includes client names and all identifiers, such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the client is sick or in the hospital, office, or clinic, the assessments and treatments the client receives, and information about past health conditions. Exceptions to confidentiality include disclosure of client information for the purpose of tracking and notification of disease outbreaks and information about a deceased person's organ donation.

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? Fill out an incident report. Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report the error to the primary provider.

Attach a copy of the incident report to the chart. For legal reasons, the nurse should not attach a copy of the incident report to the chart. The nurse should, however, stop the infusion and document the time, report the error to the primary provider and nursing supervisor, and fill out an incident report.

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply. Documenting entries that have unidentifiable writers' names and titles Documenting entries that are up to date and comprehensive Recording the date and time of all entries Documenting entries that are subjective Using approved agency abbreviations

Documenting entries that are up to date and comprehensive Recording the date and time of all entries Using approved agency abbreviations Recording the date and time of all entries, documenting up-to-date and comprehensive entries, and using agency-approved abbreviations are examples of defensible charting. Documenting entries that have unidentifiable writers' names and titles and entries that are subjective are not in line with the principles of defensible charting, as these could impede clients' safety and continuity of care.

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. If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertently adding information about other clients to the initial client's record.

Which are high-risk errors in documentation? Select all that apply. Inadequate admission assessment Failure to document completely Charting in advance Batch charting Falsifying client records

Inadequate admission assessment Failure to document completely Charting in advance Falsifying client records Although batch charting is not ideal, it is not considered a high-risk error made in documentation. High-risk errors include falsifying client records, charting in advance, failure to record changes in a client's condition, failure to document that the health care provider was notified when a client's condition changed, inadequate admission assessment, incomplete documentation, and failure to follow agency standards or policies on documentation.

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client? Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered. The client's pain should be documented on a scale of 0 to 10 when documenting the administration of pain medication. Medication that is not administered should be documented along with the reason. Steps taken to encourage the client to comply should be documented along with assessment findings.

Medication should be documented along with the time and the amount given or not given each time medication is scheduled to be administered. Accurate and timely documentation prevents medication from being administered too frequently or withheld unnecessarily. Therefore, it is most appropriate to document that the pain medication was given immediately following administration. However, in circumstances where medication cannot be given or the client refuses medication, this information should be documented with detailed information about the reason. While assessing the client's pain management is important, it is not the culminating factor to administer prescribed medication or in documenting the actual administration. While it is important to encourage clients to take the medication, if a client refuses pain medication steps taken to encourage the client to comply is not an intervention for documenting administration.

Which principle should guide the nurse's documentation of entries on the client's health care record? Correcting fluid is used rather than erasing errors. Documentation does not include photographs. Precise measurements should be used rather than approximations. Nurses should not refer to the names of health care providers.

Precise measurements should be used rather than approximations. Precise measurements and times must be used whenever possible. It is appropriate to use the names of health care providers and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Dialogue Documentation Reporting Verification

Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

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? Review the hospital's process for allowing clients to view their health care records. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.

Review the hospital's process for allowing clients to view their health care records. The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.

Which actions should the nurse take before making an entry in a client's record? Select all that apply. Reviewing the agency's list of approved abbreviations Choosing the charting format that the nurse prefers Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting Checking that clients' names are not identified within the chart forms

Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting The nurse should review the agency's list of approved abbreviations, as each agency may use a different set of approved abbreviations and has approved its use for legally defensible reasons. The nurse should locate clients' files within an electronic health record system rather than creating a new record, to avoid duplication and missing important information in the client's record that was added previously. The nurse should identify the form appropriate to use for documenting, because some aspects of clients' care are recorded on specific forms. The nurse should use the charting format required by the facility, not choose one that the nurse prefers. The client's name should be identified on chart forms, so that if the forms become separated from the chart, the nurse will still be able to identify which client chart they belong to.

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 nurse implementing? FOCUS charting SOAP charting PIE charting narrative charting

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. In what scenario is this most important? The client has had a sudden change in status needing immediate attention. The client is receiving ongoing medication therapy for a chronic disease. The client has enacted his or her rights and demanded to see all records and documentation as they occur. The client is being discharged and the nurse is providing discharge education.

The client has had a sudden change in status needing immediate attention. Computerized charting, which means documenting client information electronically, is most useful for nurses when a terminal is available at the point of care or bedside. These point-of-care (POC) systems allow for timely documentation that can be shared with multiple people and can reduce errors. This is extremely important and beneficial when a client's status has changed and frequent assessments are needed. While the POC system is efficient and can be used when administering medication or documenting discharge instruction, these are not the most probable cause for the suggestion from the provider. The client does have a right to review his or her medical records, but this would not be a reason to document in the POC system.

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 The nurse should include the client's problems, goals, and nursing orders; routine care; level of activity; and current medical orders in the client's plan of care, as this information contributes to the nursing care plan. The nurse should not include client care assignment of the nursing and support staff in the client's care plan, as this information is not specific to one client. The nurse should not include minutes from the team conference meetings, as team conferences involve discussing client care problems among selected staff members.

The nurse is completing documentation for a newly admitted client. Which entries should the nurse include in charting? Select all that apply. The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. "I feel something is going on the client isn't telling me." The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation

The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

Which documentation by the nurse best supports the PIE charting system? Vomiting 250 mL undigested food, antiemetic given, no further vomiting States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea

Vomiting 250 mL undigested food, antiemetic given, no further vomiting PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).

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

a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

What does the nurse recognize as purposes of the electronic health record? Select all that apply. documenting continuity of care qualifying health care providers for government funds ensuring client safety facilitating health education and research defending health care personnel during practice lawsuits

documenting continuity of care qualifying health care providers for government funds ensuring client safety facilitating health education and research The electronic health record provides an avenue to document continuity of care, qualify health care providers for government funds, ensure client safety, and facilitate health education and research. It can provide evidence during practice lawsuits, however, that is not the purpose of the electronic health record.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." "I am calling about the client in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will allow for us to see the client and possibly increase client participation in care." "It will let me see everything that has been done and things that need to be done." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will give me a better sense of what my workload will be today."

"It will allow for us to see the client and possibly increase client participation in care." Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

The nurse is taking verbal medication prescriptions from the provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information? Sertraline 100 mg per os HS 20:00. JD, RN. 0800-Amoxicillin 250mg PO with water. J. Doe, RN. Celecoxib 100 mg @ 0800 with applesauce, Jane Doe RN. 1200-Tramadol 50mg PO with OJ for pain rated 6 out of 10. Jane Doe RN.

0800-Amoxicillin 250mg PO with water. J. Doe, RN. When documenting information in a client's health care record, the nurse should sign each entry by name, first initial and last name, and title. Correct documentation also includes recognition of those abbreviations and terms on the "Do Not Use" list such as "per os" and "OJ" which can be confused with other terminology meanings. Time stamps should also be included in documentation.

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines? Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Yelling at staff members, dementia worse today, refused breakfast Inappropriate behavior during breakfast, screamed during the shower, smiled while kicking other clients Confused, belligerent, and uncooperative with care

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth Nursing documentation should focus on behaviors and avoid words such as better, normal, or worse. Using terms such as "inappropriate behavior" or "belligerent" is judgmental. The nurse should document only actual behaviors that the nurse witnesses.

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record? Scribble through the entry. Obtain white-out to cover the entry. Write over the entry in another color pen. Place one line through the entry and initial it.

Place one line through the entry and initial it. The appropriate action is to place one line through the entry and initial it. Any written documentation that cannot be clearly read, or that is vague, scribbled through, whited out, written over, or erased makes for a poor legal defense.

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

Subjective data should be included when documenting. Subjective data should be included when using the SOAP format for documentation. Objective data are what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care provider's judgment of the situation, and abnormal lab values would be included in objective data.

The following statement is documented in a client's health record: "Client 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. The client has symptoms in the morning associated with a heart attack. The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning.

The client reports waking up this morning with a severe headache. The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.

The client record is utilized for many purposes. Which might be uses for the client record? Select all that apply. education of student nurses reimbursement for services research giving information over the phone when unidentified callers call the hospital unit education for medical students

education of student nurses reimbursement for services research education for medical students The client medical record may be used for education of a variety of health care professionals, reimbursement, and research. The record is never used to give information to callers without written authorization from the client.

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." Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the health care provider not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? "No medical issues overnight that require immediate attention." "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety."

"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." In inpatient settings, the handoff that occurs when a new shift starts is often referred to as the change-of-shift report. This ensures continuity of client care from one shift to the next, allowing the oncoming nurse to receive information regarding the client's status or plan of care. The handoff should include objective information regarding the status of the client such as mental status, pain issues, and care performed. Subjective information is also in the handoff. This includes statements regarding anxiety. Brief, undescriptive statements are not comprehensive enough and positioning of the client, while important, is not thorough enough. Statement regarding restlessness may be important and the provider may need to be contacted, but this is not the most effective way to communicate information needed in the hand-off.

Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies? "We will discuss the new policies at the change-of-shift report." "You will demonstrate the use of the cardiac monitor on the nursing rounds." "You will see the procedure for using the new equipment in the client assignments." "We will be having a team conference to discuss concerns that clients' relatives have raised."

"We will be having a team conference to discuss concerns that clients' relatives have raised." Team conferences are effective communication strategies to discuss the relatives' concerns because this usually involves the multidisciplinary team and the relatives could be involved. Change-of-shift report is incorrect since this is only a summary of each client's condition and current status of care in a discussion between the personnel of the outgoing and incoming shifts. Client assignment identifies the clients for whom the staff person is responsible and describes their care and is therefore incorrect. Nursing rounds is incorrect since this strategy provides the staff the opportunity to observe and converse in the client's presence and boost the client's confidence.

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: Some facilities do not require them on their plans of care. Rationales are only important while the nurse is in training. The use of rationales is not commonly practiced in the clinical setting. Although not written, the nurse must know or question the rationale before performing an action. The rationale is deleted to provide additional charting space in the computer system.

Although not written, the nurse must know or question the rationale before performing an action. Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? Calling the client information desk to find out the room number of the family member Finding the emergency medical technicians who transported the family members and inquiring about the injuries Asking the emergency department nurse for information on the family member Accessing the electronic health record of the family member to find out extent of injury

Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)? Centers for Medicare and Medicaid Services The Joint Commission World Health Organization Department of Social Services

Centers for Medicare and Medicaid Services The HITECH Act was established in 2009 to create incentives for professionals and agencies to receive financial payment for the meaningful use of technology to improve client care. The Centers for Medicare and Medicaid Services is the agency responsible for monitoring compliance to HITECH. The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. The World Health Organization is a specialized agency of the United Nations that is concerned with international public health. There is a department of social services in each state that focuses on benefits and facilities such as education, food subsidies, health care, police, fire service, job training and subsidized housing, adoption, community management, policy research, and lobbying.

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting? Ensure that the client's name appears on all pages. Leave spaces between entries and signature. Use abbreviations wherever possible. Record all facts and subjective interpretations.

Ensure that the client's name appears on all pages. The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts, but not any subjective interpretations, to ensure that the document is legal evidence.

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 Nurse's shift report Transfer report Telemedicine report

Incident report An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

A client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report? Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes. MR#12345, Alfred Jones, 76-year-old male 8 days post-op for RVEF. Transferring for monitoring for the next week. Braden score 13 and vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr with orders to continue for 3 days. Pain at incision rated at 4 on a scale of 0-10 relieved with a combination of oxycodone and acetaminophen at 0845 with relief within 30 minutes. Mr. Alfred Jones, 8 days post-CABG to correct RVEF is being transferred to the telemetry unit. Vitals are BP 130/82, P 82 and irregular, R 21, T 99.2F (37.3C). Client is currently receiving D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Oxycodone pain medication administered at 0800 along with PRN acetaminophen. Alfred Jones, 76-year-old male-Transferring for monitoring for the next 7 days. Vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr. Pain at incision relieved with a combination of oxycodone and acetaminophen at 0845.

Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes. The nurse should include the current assessment of the client in the verbal handoff summary because it enables the receiving nurse to prepare for the client before arrival. It also allows the receiving nurse to clarify any information that may appear on the written handoff form. Additionally, the nurse should also report the presence of any intravenous fluids and the presence of advanced directives. It is not important to mention the client's medical record number during the communication. Information about intake for the previous meal would only be important if these were directly influencing the client's current status.

Which statement regarding FOCUS charting is most accurate? The charting focuses on client strengths, problems, or needs. The charting focuses on the injury or illness only. Problem, intervention, evaluation (PIE) charting is used with FOCUS charting. Each note should include each section of the data, action, response (DAR) format of charting.

The charting focuses on client strengths, problems, or needs. FOCUS charting focuses on client strengths, problems, or needs. The injury or illness is not the only focus of this form of charting. PIE charting is separate from FOCUS charting. When using the DAR format, not every area needs to be addressed with each entry.

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his or her charting? Select all that apply. The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." The client seems depressed. The client is suicidal. The client is in a bad mood.

The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." When documenting observations of client behavior, the nurse must maintain objectivity by describing the actual behaviors, rather than attempting to interpret the behaviors. For example, the nurse should not describe the client as depressed or angry. The nurse should document any statements made directly by the client.

A client's record can be more accurate if the nurse: charts at least every 6 hours. uses point-of-care documentation. summarizes client care at the end of the shift. delegates charting appropriately.

uses point-of-care documentation. Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation. The nurse should not delegate documentation, nor should it be left to the end of a shift. Documentation should be performed more than once every 6 hours.

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. "I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space." "I will stay logged in on the computer until the end of my shift." "I will elaborate on the details on my entry in the clients' records."

"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space." Writing, printing, or typing information legibly will prevent the entry from losing its value for exchanging information if it is unreadable. Using only agency-approved abbreviations promotes consistency in interpretation. Drawing a straight line through any blank space will reduce the possibilities that someone else will add information to the current documentation. Staying logged in on the computer until the end of the shift is incorrect, as it is a security risk. Best practice is that the nurse logs off each time the nurse has completed an entry. Elaborating on the details on the entry in the clients' records is not in keeping with best practice. The entry should be brief but complete.

The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A recommendation for pain management by the emergency department health care provider who admitted the client a week ago A conversation addressing the need for durable medical equipment when the client goes home

A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A conversation addressing the need for durable medical equipment when the client goes home Care plan conferences are discussions about client care, usually involving several disciplines. Interdisciplinary conferences help to coordinate services so that the client's plan of care can be developed and implemented in the most efficient way. Nurses may initiate these conferences and invite members of the health care team from other departments (e.g., physical therapy, social services, dietary). Clients who most benefit from such conferences are those with multiple, complex problems. The emergency health care provider is no longer needed to address care provided in the health care facility.

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take? Review the nursing care plan. Implement changes in the current interventions. Involve the family in changes. Revise the plan of care.

Revise the plan of care. A plan of care should be generated at admission and reviewed regularly. The care plan must be revised to reflect changes in the client's condition. Changes in the care plan will then reflect new interventions to address those changes. The family will not be directly involved in any changes in nursing care.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. S: The nurse handling the transfer describes the client situation to the new nurse. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse explains the rules of the new facility to the client. R: The nurse gives recommendations for future care to the new nurse in charge.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge. Examples of using the SBAR technique are numerous. The nurse handling the transfer describes the client situation to the new nurse. The nurse gives the background of the client by explaining the client history. The nurse presents an assessment of the client to the new nurse. The nurse gives recommendations for future care to the new nurse in charge. The nurse does not explain the rules of the new facility to the client as part of the SBAR technique. The nurse would discuss the client's symptoms with the new nurse in charge as part of the "B" background, not the "S" situation.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Disclosing client health information for research purposes after obtaining permission from the client's health care provider Releasing the client's entire health record when only portions of the information are needed Submitting a written notice to all clients identifying the uses and disclosures of their health information Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

Submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the health care provider's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. interpretation of data. important information. relevant data.

interpretation of data. A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

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 Only those directly involved in client care are entitled to access the client's information. Family members and close friends do not have access to the client's records, as per the privacy policy applicable to each client. Health care professionals of the health care facility may not access client information unless involved in that client's care at that time..

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. Fever, possible urinary tract infection "I don't feel well. I've been urinating often, and it burns when I urinate." Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. When using the SOAP format, the nurse would first document the subjective data (S: the client's complaint), objective data (O: abdomen, urine characteristics, temperature and contributing factors), assessment (A: caregiver's judgment about the situation—fever and possible urinary tract infection), and plan (P: what the caregiver is going to do—notify the health care provider, encourage fluids, and continue to monitor).

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? "Legal policy requires nursing practice to be permanently integrated into the client record." "It would be easier to do it that way. You could develop a tool to use." "The facility requires us to document client care this way because of the computer application used." "The electronic health record we use does not allow us to use different formats."

"Legal policy requires nursing practice to be permanently integrated into the client record." Legal policy requires nursing care documentation to be permanently integrated into the client record. Computer applications and electronic health record formats may have some differences, but they all use an integrated record. Suggesting that the nurse develop a new tool would be inappropriate, as separate nursing documentation would not be legal.

The nurse is caring for a postoperative client who is experiencing hypotension. When contacting the client's health care provider, the nurse will include which statement in the SBAR report? Select all that apply. "I have diagnosed the client with an internal bleed and need orders to treat accordingly." "The client demonstrates additional signs of hypovolemia including slow capillary refill." "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." "The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery." "The client is very distressed. I am very concerned about how the client is coping right now."

"The client demonstrates additional signs of hypovolemia including slow capillary refill." "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." "The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery." When notifying the health care provider about a change in a client's condition, the nurse documents in the client's record the information reported and the instructions received. In an effort to improve client safety by improving staff communication and identifying client safety risks, the SBAR format has been recommended as a model for effective communication. SBAR refers to S (Situation): What is the situation about which you are calling, B (Background): Pertinent background information related to the situation, A (Assessment): What is your assessment of the situation?, R (Recommendation): Explain what is needed or wanted. The SBAR does not require the nurse to formulate a medical diagnosis. It is not within the nurse's scope to conclude that the client has an internal bleed, instead, the nurse would make a recommendation for what is needed, for example, for the health care provider to attend the client and assess further. While it is important to respond to the client's needs, if they are distressed, the nurse will not include this information in the SBAR because it does not focus on the issue that needs to be immediately prioritized which is the sudden hypotension.

HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply. The nurse uses sign-in sheets that contain information about the reason for the client visit. A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse uses white boards on an unlimited basis. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. The nurse leaves a detailed appointment reminder message on a client's voice mail.

A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit. Examples of incidental disclosures of client health information that are allowed by HIPAA regulations include: a visitor hearing a confidential conversation when the nurses are in appropriate surroundings and using low voices; the use of x-ray light boards that can be seen by a passersby as long as the x-rays are not left unattended by the health care staff; the calling out of names in the waiting room when the reason for the client visit is not disclosed. The following are not allowed by HIPAA regulation: the nurse using a sign-in sheet that contains information about the reason for the visit; the use of white boards on an unlimited basis; the nurse leaving a detailed appointment reminder message on a client's voice mail. It is important that the nurse is aware of HIPAA regulations and common examples of incidental disclosures that are considered allowed in the nurse's work setting.

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. The nurse asks the health care provider to describe the admitting diagnosis of the client. After introductions, the nurse states the client name, room number, and problem. The nurse asks the health care provider to estimate the discharge date for the client. The nurse asks the health care provider to comment on the present situation before giving recommendations. The nurse states that the client's condition "could be life-threatening." The nurse reads back the health care provider's new orders at the conclusion of the call.

After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse reads back the health care provider's new orders at the conclusion of the call. The ISBARR format is an effective tool for communication in the health care setting. This template outlines the conversation to occur between the nurse and the health care provider in the question above. The nurse would perform the following actions when using this guide: • after introductions, the nurse would state the client name and other important demographic information regarding the client • the nurse could potentially state that the client's condition "could be life-threatening," • the nurse reads back the health care provider's new orders at the conclusion of the call.The nurse would not ask the health care provider to describe the admitting diagnosis of the client. The nurse would not ask the health care provider to estimate the discharge date for the client. The nurse would not ask the health care provider to comment on the present situation before giving recommendations.

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? Immediately delete the incorrect documentation. Create an addendum with a correction. Contact information technology (IT) staff to make the correction. Contact the health care provider.

Create an addendum with a correction. If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Making the names of clients on charts visible to the public

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Obscuring identifiable names of clients and private information about clients on clipboards; placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The health care provider, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? FOCUS charting narrative charting PIE charting SOAP charting

SOAP charting In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. Showing the provider the trends from baseline to present in blood pressure Informing the provider of the client's present heart rate of 116 beats/min Faxing the results of blood chemistry levels to the provider's office Writing the hemoccult result on a piece of paper and leaving it at the desk Placing a note on the computer terminal with the client's name and information

Showing the provider the trends from baseline to present in blood pressure Informing the provider of the client's present heart rate of 116 beats/min Faxing the results of blood chemistry levels to the provider's office Reporting to the primary care provider can occur face-to-face, by telephone, by text messaging, or, in some settings (e.g., long-term or home care), by fax. Placing a note on a computer terminal with client information or writing the hemoccult results on a piece of paper and leaving it at the desk is a violation of the Health Insurance Portability and Accountability Act because the information is visible and accessible to anyone passing by. The other answers are appropriate ways to communicate client information to a health care provider while protecting the client's confidentiality.

The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include? Select all that apply. The client's blood pressure trend over the past 24 hours. The primary reason the client was admitted to the hospital. Objective and subjective data from the most recent assessment. An explanation of what is needed to improve the hypotensive state. A history of chronic health conditions affecting the client's family. A review of the full client Kardex with the health care provider.

The client's blood pressure trend over the past 24 hours. The primary reason the client was admitted to the hospital. Objective and subjective data from the most recent assessment. An explanation of what is needed to improve the hypotensive state. When notifying the health care provider about a change in a client's condition, the nurse documents in the client's record the information reported and the instructions received. In an effort to support The Joint Commission's National Patient Safety Goals regarding the improvement of staff communication and identifying client safety risks, the SBAR format has been recommended as a model for effective communication. The SBAR includes: (1) S (Situation): What is the situation about which you are calling? (2) B (Background): Pertinent background information related to the situation; (3) A (Assessment): What is your assessment of the situation? (4) R (Recommendation): Explain what is needed or wanted. For the client who has a change in the vital signs, such as low blood pressure, that change is a sign that there is a problem that warrants an intervention. To be most efficient with the client report, the nurse will include the situation, which includes the current blood pressure reading and a trend over the past day to highlight the change is significant. The nurse will include the background, which is the main reason the client was admitted to the hospital. This information provides some context as to why the current problem may be occurring. The nurse's assessment report will include both objective data (that which can be quantified) and subjective data (which is the nurse's observation of signs and symptoms that cannot be measured). The nurse's report will also include a brief statement about what might be needed to respond to the problem being reported. In some cases, the nurse may not know what is needed, but with experience, a recommendation to the health care provider can be formulated in advance and the nurse can work collaboratively with the health care provider to generate the best intervention. It is not relevant to provide the client's family history of chronic health conditions. This information would create time inefficiency and will not influence the health care provider's decision about what immediate intervention is required. The client Kardex is a quick communication tool between nurses to communicate the client's needs and brief notes about client status. Reading the full Kardex to the health care provider would be an inefficient use of time when a decision needs to be made with associated time pressure.

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply. The content reflects client needs. The content includes descriptions of situations that are out of the ordinary. The content is not in accordance with professional standards. There are lines between the entries. The documentation is not countersigned. Dates and times of entries are omitted.

The content is not in accordance with professional standards. There are lines between the entries. Dates and times of entries are omitted. Incomplete and incorrect documentation by the nurse can potentially increase the nurse's risk for legal problems. The following documentation errors may potentially increase the nurse's risk for legal problems: the content is not in accordance with professional standards; dates and times of entries are omitted. The following documentation would not increase the nurse's risk for legal problems: the content reflects client needs; the content includes descriptions of situations that are out of the ordinary; the documentation is not countersigned.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can accept verbal orders to provide immediate care and record once the client is stable. The provider can input orders remotely into the EHR system for the nurse to retrieve. The nurse can implement care once written orders are received from the provider. The client must be stabilized before the nurse can obtain any orders from the provider.

The nurse can accept verbal orders to provide immediate care and record once the client is stable. In most agencies, the only circumstance in which the attending health care provider, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the health care provider/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Health care provider can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? The nurse could be fined or even go to jail for violating HIPAA. No action will be taken as long as the parents don't find out. There will be no repercussions if the nurse takes the photo down from the social media page. The nurse could be fired but would not face criminal charges or jail time.

The nurse could be fined or even go to jail for violating HIPAA. The nurse has committed a HIPAA violation and most likely breached the facility's social media policy. The nurse has placed a newborn and family at risk by posting photos to a social media website where anyone is at liberty to view the page. The nurse may well be dismissed for this infraction and is at risk for fines and imprisonment for a HIPAA violation, even if the nurse takes the photo down and the parents do not find out. The managers at the facility should enforce the social media policy, explain violations and consequences to all staff, and have them sign the social media policy.

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. The nurse provides information to a professional caregiver involved in the care of the client. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell.

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it. Translators may need additional explanations of medical terms.

Translators may need additional explanations of medical terms. When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.

A nurse is working with the case management model and using a collaborative pathway. The nurse notes that the client has not met an expected outcome and documents this using occurrence charting. When completing this documentation, what information would the nurse include? Select all that apply. Unexpected event Cause of the event Actions taken in response to the event Goals Incident report recording

Unexpected event Cause of the event Actions taken in response to the event When a client fails to meet an expected outcome or a planned intervention is not implemented in the case management model, this variance from the plan is documented. The usual format for occurrence charting or variance charting is the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate. Goals and an incident report would not be documented in occurrence charting.

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. Document lengthy entries using complete sentences. Use PIE charting, even if it is not the institution's charting method. Only document changes in the client's status.

Use abbreviations approved by the facility. Use abbreviations, but only those that are commonly accepted and approved by the facility. All documentation requires proper grammar and writing techniques. The nurse should be using the particular charting method for the employing institution. All care and observations should be documented - not only changes in a client's status.

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. Which of the following best defines this type of charting? charting by exception (CBE) FOCUS charting problem, intervention, evaluation (PIE) charting variance charting

charting by exception (CBE) 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 the narrative notes. Charting by exception decreases charting time. FOCUS charting does not use a problem list of nursing or medical diagnoses, but incorporates many aspects of the client and client care into a FOCUS column. The focus may be a client strength, problem, or need. Problem, intervention, evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome, or when a planned intervention is not implemented in the case management model.

The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation? immediately report the suspected abuse of the client. avoid reporting the abuse as it would be a privacy and confidentiality violation inform the client's family that the client is being neglected at home discuss the abuse with coworkers to determine what should be done

immediately report the suspected abuse of the client. The nurse is a mandatory reporter and state laws take precedence over Health Insurance Portability and Accountability Act (HIPAA)/ Personal Information Protection and Electronic Document Act (PIPEDA) regulations. The priority action by the nurse is to report the suspected abuse to the adult protective service department so that it can be investigated. It is not appropriate to involve the family members at this point because it may mask any abuse that is occurring. The fewer people involved in this situation is better. The nurse should not discuss this with coworkers unless they are directly involved with the client's care.