PREPUTEST4LECTURE

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

The nurse documents clients' responses to nursing interventions. Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

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." Explanation: 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. Reference:

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."

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?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?" SBAR is an acronym for Situation, Background, Assessment, Recommendation. Situation is what the nurse describes, the current situation. Background is the pertinent information regarding the current situation. Assessment is objective information that supports the situation. Recommendation is what the nurse recommends to the health care provider. In this case, the Recommendation is the nurse asking the provider to prescribe a complete blood count and culture. "I am concerned that the client might be exhibiting sepsis" is a situation statement. "The client's temperature has been 102°F (38.9°C) for the last 6 hours" is the assessment of the client supporting the situation. The client being admitted today with a urinary tract infection is Background.

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

Which clinical situation 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 health care provider wrote in his chart.

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 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 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:

Although not written, the nurse must know or question the rationale before performing an action.

Which are appropriate actions for protecting clients' identities? Select all that apply.

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

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

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.

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. 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.

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

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.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

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 organization audits charts regularly?

The Joint Commission

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 nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

Which is not a purpose of the client care record?

To serve as a contract with the client Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.

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? Select all that apply.

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

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

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

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 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 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.

In SBAR, what does R stand for?

recommendations

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 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.