prepu chapter 20

subjective data, which are usually recorded as the client's statement or anything verbalized by the client. (of SOAP)

"A," or assessment, portion of the SOAP

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."

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. They have new onset diabetes mellitus. Their blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

statements about the abdomen being soft, bowel sounds, and so on reflect the (of soap)

"O," or objective data, portion of the SOAP

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 are an obstruction to research and education."

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?

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

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 variance

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

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.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

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

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.

A nurse is working at a first job. When completing client documentation, the nurse should perform which action?

Only use abbreviations approved by the facility.

PVD

Peripheral vascular disease

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client 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

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse?

Read back the prescription. Record the date and time of the prescription. Include V.O. with the health care provider's name on the prescription.

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the health care provider's information in the health care provider's progress notes. The nurse is using which method of documentation?

Source-oriented

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Submitting a written notice to all clients identifying the uses and disclosures of their health information

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to?

The Joint Commission

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

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment?

The lower extremities

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

The nurse is finding it difficult to plan and implement care for a client 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 client care.

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?

Translators may need additional explanations of medical terms.

A nurse has begun a new role on a high acuity unit where clients' health status often change rapidly. What practice should the nurse adopt to maximize the accuracy of documentation?

Use point-of-care documentation whenever possible.

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.

Verbal orders should only be accepted during

an emergency

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include?

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

Focus charting method brings the focus of care

back to the client and the client's concerns Instead of a problem list or list of nursing or medical diagnoses

Nursing documentation should focus on

behaviors and avoid words such as better, normal, or worse.

Point-of-care documentation takes place as

care occurs, thus enhancing accuracy.

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.

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)

A variance occurs when the

client does not proceed along a clinical pathway as planned.

What ensures continuity of care?

communication

CABG

coronary artery bypass graft

All care and observations should be

documented - not only changes in a client's status.

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

The plan of care identifies

methods for solving each identified health problem.

A source-oriented record is a

paper format in which each health care group keeps data on its own separate form.

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?

progress notes

Audits of client records serve a dual purpose:

quality assurance and reimbursement.

When using the PIE charting method, assessments are documented on

separate forms

In the SOAP format, "S" refers to

subjective data, which are usually recorded as the client's statement or anything verbalized by the client.

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 the client is making progress in expected outcomes of care

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

the public health department

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