NUR162 Ch16 prepU
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
"A coronary artery bypass graft will benefit your heart."
A nursing instructor is discussing a nursing student's Facebook post about a very interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate?
"Any information that can identify a person is considered a breach of client privacy."
A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate?
"It will allow for us to see the client and possibly increase client participation in care."
A nurse helps a patient who has cystic fibrosis prepare a standalone personal health record. Which statement by the nurse best explains this type of information?
"You can fill in information from your own records and store it on your computer or the Internet."
A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? (Select all that apply.)
-Quality improvement • Research • Decision Analysis • Financial reimbursement
The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given?
2130
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?
A client has asked a nurse if he can read the documentation that his physician wrote in his chart.
A nurse is arranging for home care for patients and reviews the Medicare reimbursement requirements. Which patient meets one of these requirements?
A patient who is homebound and needs skilled nursing care
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
A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format?
Charting by exception
A nurse administering medications accidentally gives a double dose of blood pressure medications. After ensuring the safety of the client, the nurse would document the error in which documents?
Client's record and occurrence report
A nursing supervisor overhears one of the staff nurses say, "I only document vital signs when they are out of the normal range." What action by the nursing supervisor should be implemented first?
Discuss with the staff nurse that the recording of all client data, even when normal, is important in providing and evaluating care.
According to the American Nurses Association (ANA), what is the primary source of evidence to measure performance outcomes against standards of care?
Documentation
When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?
Ensure that the client's name appears on all pages.
An area of specialization in nursing that is a combination of computer science, information science, and nursing science is termed
Informatics
What action by the nurse best demonstrates a consultation?
Involving social services in client care to obtain needed prescriptions
How can the nurse researcher obtain information from a client record?
Study client records
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.
Which statement regarding focus charting is most accurate?
The charting focuses on client strengths, problems, or needs.
A client has been diagnosed with PVD. What area of the body should the nurse focus the assessment?
The lower extremities
The nurse is finding it difficult to plan and implement care for a patient and decides to have a nursing care conference. What action would the nurse take to facilitate this process?
The nurse meets with nurses or other health care professionals to discuss some aspect of patient care.
A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?
To investigate the quality of care in the agency
A new graduate is working at her first job. Which statement is most important for the new nurse to follow?
Use abbreviations approved by the facility.
Which documentation by the nurse best supports the PIE charting system?
Vomiting 250 ml undigested food, antiemetic given, no further vomiting
A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?
Write a narrative note in the designated nursing section.
A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which people would be entitled to access of the client's records?
those directly involved in the client's care
The nurse is using the ISBARR format to report a surgical patient's deteriorating condition to a physician. Which actions would the nurse perform when using this guide? (Select all that apply.)
• After introductions, the nurse states the patient name, room number, and problem. • The nurse states that the patient's condition "could be life-threatening." • The nurse reads back the physician's new orders at the conclusion of the call.
What information should the nurse document in the medication record when administering a non-narcotic pain medication? (Select all that apply.)
• Time • Dose • Reason given • Effectiveness of medication
Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?
A graphic sheet
A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for patients diagnosed with multiple sclerosis, and their families. Providing this information is an example of which of the following?
A referral
What ensures continuity of care?
Communication
What is the primary purpose of the patient record?
Communication
A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation?
Communication is the primary purpose of client records.
A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?
Current client assessment
A physician is in a hurry to leave the unit and tells the nurse to give a morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?
Inform the physician that a written order is needed.
Besides being an instrument of continuous client care, the client's medical record also serves as a(an):
Legal document
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
Limiting abbreviations to those approved for use by the institution.
Which principle should guide the nurse's documentation of entries on the client's medical record?
Precise measurements should be used rather than approximations.
A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication?
Rates pain 8/10, states nauseated for last 30 minutes.
Which organization audits charts regularly?
The Joint Commission
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients:
have the right to copy their health records.
The parent of a 33 year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate?
Ask the client if information can be given to the parent.
A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?
Identifying risks and ensuring future safety for clients
Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting?
If I make an error, I draw a single line through it and put my initials by it.
The nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?
Incident report
A physician suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for the physician's suggestion?
It keeps the nurse close to the source of the data.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?
Nutritional consult
A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?
Problem-oriented method
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes
How can a nurse obtain additional information about a client?
Read the client's history and assessment.
The nurse hears a nursing assistant discussing a client's allergic reaction to a medication with another nursing assistant in the cafeteria. What is the highest priority nursing action?
Remind the nursing assistant about the client's right to privacy.
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Reporting
The nursing is caring for a client who requests to see a copy of his or her medical records. What action by the nurse is most appropriate?
Review the hospital's process for allowing clients to view their medical records.
When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?
SOAP Charting
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
A coronary artery bypass graft will benefit your heart
A patient accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?
Accurately documenting patient care on the patient record
A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest?
Charting by exception
An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. What response by the nurse is most appropriate?
Explain the reason why information cannot be disclosed.
A nurse takes a patient's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?
Graphic sheets
The doctor tells the client, "You are experiencing a MI," and leaves the room. The client asks the nurse what a MI stands for. What response by the nurse is most accurate?
Myocardial Infarction
A health care facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietitian, and the nurse involved in the client's care are required to collate all of the information for easy access. Which style do you think the agency is following in order to record the client details?
SOAP charting
A nurse has a two-way video communication with the specialist involved in the care of a patient in a long-term care facility. This is an example of what nursing informatics technology?
Telemedicine and mobile technology
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.
A nurse is giving a verbal report to a physician using the ISBAR communication technique regarding a client with signs and symptoms of fluid volume deficit. Which statements should the nurse include in the report? (Select all that apply.)
• "I am the nurse assigned to the client." • "The client has been complaining about dizziness when walking." • "The client vomited twice and has dry mucous membranes." • "Current blood pressure is 90/50 mmHg with a pulse of 112 BPM." • "I encourage the client to take sips of fluid after giving the ordered antiemetic."
