PREP U CHAP 10

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

A)Centers for Medicare and Medicaid Services

What is the primary purpose of the client record? A)Communication B)Advocacy C)Research D)Education

A)Communication

In SBAR, what does R stand for? A)Reinforcing data B)Response C)Recommendations D)Report

C)Recommendations

Which strategy would provide the most effective form of change of shift report? A)Recording the report for the oncoming shift prior to leaving the unit. B)Discussing the client's visitors and complaints during the prior shift. C)Providing the oncoming nurse the client's clipboard prior to leaving the unit. D)Utilizing a reporting form and allowing time for any questions.

D)Utilizing a reporting form and allowing time for any questions.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? A)The client reports waking up this morning with a severe headache. B)The client has symptoms in the morning associated with a heart attack. C)The client is coughing and experiencing severe heartburn in the morning. D)The client has a history of severe complaints in the morning.

A)The client reports waking up this morning with a severe headache.

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)a referral. B)a consultation. C)conferring. D)reporting.

A)a referral.

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

A)identifying risks and ensuring future safety for clients

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

B)Obscuring identifiable names of clients and private information about clients on clipboards C)Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D)Keeping record of people who have access to clients' 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 nurse implementing? A)FOCUS charting B)SOAP charting C)PIE charting D)narrative charting

B)SOAP charting

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

B)interpretation of data.

Which are appropriate actions for protecting clients' identities? Select all that apply. A)Orient computer screens toward the public view. B)Ensure that clients' names on charts are visible to the public. C)Document all personnel who have accessed a client's record. D)Place light boxes for examining X-rays with the client's name in private areas. E)Have conversations about clients in private places where they cannot be overheard.

C)Document all personnel who have accessed a client's record. D)Place light boxes for examining X-rays with the client's name in private areas. E)Have conversations about clients in private places where they cannot be overheard.

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

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

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message? A)The laboratory assistant does not have the correct password. B)The laboratory assistant does not have the correct access number. C)The laboratory assistant can only retrieve patient records but cannot view the details. D)The laboratory assistant is trying to view archived data.

C)The laboratory assistant can only retrieve patient records but cannot view the details.

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

C)The nurse documents clients' responses to nursing interventions.

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? A)"I am concerned that the client might be exhibiting sepsis." B)"The client's temperature has been 102°F (38.9°C) for the last 6 hours." C)"The client was admitted today with a urinary tract infection." D)"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

D)"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes? A)Correct the abbreviations in the EHR. B)Ask another nurse to fix the abbreviations. C)Contact the facility's information technology department to delete abbreviations. D)Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

D)Suggest to the nurse manager that an in-service on abbreviation use would be helpful.