Chapter 19: Documenting and Reporting (1)

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? pg. 457

"I will arrange access for you to review the record after you put your request in writing."

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? pg. 469

It provides quick access to abnormal findings.

Which is the proper way to document midnight in a client's record? pg. 456

0000

The nurse cared for a client admitted with uncontrolled hypertension. The client suffered a stroke shortly after the nurse's shift ended. Which information will determine if the nurse is liable? pg. 454

Omitting documentation of blood pressure at the end of the shift

Which finding from a nursing audit reflects high standards for client safety and institutional health care? pg. 453-456

The nurse documents clients' responses to nursing interventions.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: pg. 456

interpretation of data.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? pg. 469

urine output 100 ml

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? pg. 477

"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."

Which organization audits charts regularly? pg. 464

The Joint Commission

The nurse is providing documentation for the care rendered to clients. Which characteristics identify documentation as effective? Select all that apply. pg. 455

- Readable - Thoughtful - Timely - Clear, concise, and complete

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? pg. 456

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? pg. 457

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 clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? pg. 472

a client who is homebound and needs skilled nursing care

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? pg. 456

2015

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given? pg. 456

2130

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? pg. 456

1 Unit of glucose

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? pg. 455

Calling the client information desk to find out the room number of the family member

Which statement is not true regarding a medication administration record (MAR)? pg. 471

If the client declines the dose, the nurse does not have to document this on the MAR.

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? pg. 469

charting by exception

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? pg. 478

Incidence report