NU270 Quality Improvement
A bedridden client is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as 0800 and 1200 0800 and 2200 0800 and 2000 800 and 2200
0800 and 2000 Explanation: 8:00 a.m. is 0800 in military time and 8:00 p.m. is 2000.
Which attribute is a benefit of health care providers using an evidence-based practice guideline? It directs research into forming a diagnosis and treatment for a certain condition. Once a practice guideline is well developed, it does not require modification. With continued use, it will decrease healing time for clients. It uses one research method for delivery of care.
It directs research into forming a diagnosis and treatment for a certain condition. Explanation: Evidence-based practice guidelines often use methods to combine evidence from different studies to produce a more precise estimate of the accuracy of a diagnostic method or the effects of an intervention method. Practice guidelines require continuous updates as new research is conducted and supported. Practice guidelines are developed on numerous research studies. Not all research is directed toward healing time.
A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? Meet with the new nurse and question the new nurse about deficits in performance. Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process. Meet with the new nurse and the primary nurse and help set up an additional week of orientation. Explain to the primary nurse that a 6-week orientation is standard.
Meet with the new nurse and the primary nurse and help set up an additional week of orientation. Explanation: The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation does not mean that a nurse is not competent or that there are deficits in performance. Although a 6-week orientation may be standard, orientation periods should be individualized to meet the needs of the staff as well as provide the best client outcomes. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete the orientation as efficiently as possible.
A client is admitted to the emergency department after having taken several barbiturates and drinking a pint of vodka. What is important for the nurse to continuously monitor for this client? Monitor for seizure activity. Monitor for respiratory depression. Monitor blood glucose levels. Monitor electrolyte levels.
Monitor for respiratory depression. Explanation: Barbiturates have a significant synergistic effect with alcohol and the client must be monitored for respiratory depression even after interventions have been performed.
The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement? Evaluation Implementation Assessment Planning
Planning Explanation: Establishing the outcomes and actions will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
Which organization audits charts regularly? National League for Nursing Sigma Theta Tau International American Nurses Association The Joint Commission
The Joint Commission Explanation: The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .
Which characteristic is the most important indicator of high-quality nursing practice? The nurse considers the individual needs of clients. The nurse follows the policies and procedures of the institution. The nurse takes measures to ensure accurate medication administration. The nurse is organized and efficient in client care.
The nurse considers the individual needs of clients. Explanation: The personal, compassionate, caring side of a nurse is the most important indicator of quality nursing care. Considering the individual needs of the clients demonstrates the nurse's belief in the importance of the client. Being organized and efficient, following policies and procedures, and ensuring accurate medication administration are important parts of nursing care but are mainly task oriented.
The neuroscience nursing unit has developed a set of step-by-step directions of what should occur if a nursing assessment reveals the client may be exhibiting clinical manifestations of a cerebrovascular accident (CVA). Which statement about clinical practice guidelines are accurate? Select all that apply. The development of evidence-based practice guidelines require a research review from different studies to develop the most accurate diagnostic method to implement. A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method. When developing a CVA set of step-by-step directions, the nursing unit should ask for assistance from experts in the neuroscience field. The potential users of the guidelines should pilot test it for further feedback. Step-by-step guidelines are usually developed and based primarily on "how it has always been done before." Once developed, practice guidelines only need to be reviewed if a national committee sends out an update on new research.
The development of evidence-based practice guidelines require a research review from different studies to develop the most accurate diagnostic method to implement. When developing a CVA set of step-by-step directions, the nursing unit should ask for assistance from experts in the neuroscience field. The potential users of the guidelines should pilot test it for further feedback. A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method. Explanation: Clinical practice guidelines are systematically developed and intended to inform practitioners in making decisions about health care for CVA clients. They should be developed using research and review by experts in the clinical content. Potential users should also participate and provide feedback prior to implementation. The purpose of the guidelines is to review EBP articles and develop new practice guidelines rather that continuing practicing primarily on "how it has always been done before." Once developed, the guidelines must be continually reviewed and changed to keep pace with new research findings. A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method or the effects of an intervention method. Better patient outcomes Explanation: Magnet® hospitals have better patient outcomes than facilities without the recognition. Magnet® hospitals have higher nurse retention and job satisfaction scores, but these do not have a direct effect on client care. Magnet® hospitals have shorter, not longer, patient stays.Family-centered pediatric care Explanation: Evidence-based practice has become the standard that nurses are to strive for in caring for their clients. By involving the family in caring for ill children, the child and the family are better served and have improved outcomes. Parental interaction is encouraged for preterm infants to foster bonding. Children and adults need to be separated on inpatient units to ensure that the caregivers have a clear understanding of each client's needs, since children are not small adults. Centralized care has proved to be most beneficial to client outcomes by providing resources and specialists in one location.
Which characteristic is the most important indicator of high-quality nursing practice? The nurse considers the individual needs of clients. The nurse is organized and efficient in client care. The nurse follows the policies and procedures of the institution. The nurse takes measures to ensure accurate medication administration.
The nurse considers the individual needs of clients. Explanation: The personal, compassionate, caring side of a nurse is the most important indicator of quality nursing care. Considering the individual needs of the clients demonstrates the nurse's belief in the importance of the client. Being organized and efficient, following policies and procedures, and ensuring accurate medication administration are important parts of nursing care but are mainly task oriented.
While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? making a copy of the incident report for the client submitting the incident report to the appropriate hospital administrator documenting the incident factually in the client's record notifying the health care provider of the incident and the client's condition
making a copy of the incident report for the client Explanation: A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.
When caring for a client with alcohol dependence who is prescribed a benzodiazepine, which side effects is it most important that the nurse monitor for? anxiety insomnia increased thirst sedation
sedation Explanation: The side effects of benzodiazepines are sedation, confusion, restlessness, bradycardia, tachycardia, urinary retention or incontinence, and drug dependence. The nurse should observe the client for excessive sedation and should use benzodiazepines cautiously in clients with impaired kidney or liver function. Insomnia, increased thirst, and anxiety are common side effects in drugs used in recovery from chemical dependence, but are not most commonly associated with benzodiazepines.
Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which statement indicates the primary reason the nurse manager would perform an investigation to determine the causes of the falls? "I want to identify the environmental factors that contributed to the falls." "I would like to establish the causes and trends related to client falls." "I would like to know which staff members were on duty when the falls occurred." "I want to determine exactly what happened and why the two clients fell."
"I would like to establish the causes and trends related to client falls." Explanation: The analysis will identify variations in performance that cause or could cause the clients to fall. It will identify the answer to the question of "How can we prevent this from happening again?" It does not place blame on individuals; rather, it looks at systems and processes. Limiting the focus of the inquiry to the specific clients or staff members does not meet the criteria for root cause analysis, because those foci are too narrow in scope. Similarly, limiting the inquiry to only environmental factors could result in missed data important to the contributing factors for the falls. The nurse examines all potential contributing factors to develop the most helpful investigation.
Which statements made by a nurse would indicate to a nurse manager that the nurse requires further training? Select all that apply. "I will have the supervisor fill out the incident report when I make an error." "When I document, I make sure it is factual, accurate, complete, and timely." "If I make a mistake, I will not tell anyone." "I am accountable for any task that I delegate." "The nursing plan of care must be accurate and must be followed. It is part of the client's permanent record."
"If I make a mistake, I will not tell anyone." "I will have the supervisor fill out the incident report when I make an error." Explanation: Nurses should report errors and mistakes and complete incident reports themselves, not have supervisors do it. Documentation should be accurate, factual, complete, and timely. Nurses are accountable for any designated task. The nursing plan is part of the client's permanent record.
The researcher must critically appraise evidence following a literature review. Which questions should the researcher pose in this appraisal? (Select all that apply.) "What were the results of each study?" 'Will the results of each study improve client care?" "How many studies were found during the review?" "Are the results of each study valid and reliable?" "Where was each study conducted?"
"What were the results of each study?" "Are the results of each study valid and reliable?" 'Will the results of each study improve client care?" Explanation: Although the number of studies found and where the studies were conducted could be important to the researcher, they are not the basis for a critical appraisal of the evidence. The critical appraisal should focus on the results of studies, the reliability and validity of those studies, and the importance of the studies to client care.
An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next? Test Implement Analyze and Plan Train
Analyze and Plan Explanation: Evaluation may be the last phase of the system development lifecycle, but it represents an essential step for nurses to be involved in before circling back to Analyze and Plan based on the results of the evaluation. This step is important to complete before making updates or improvements to a system already in place. Once this step is completed, the other steps of the system development lifecycle would follow.
The nurse is working at a facility that is applying for Magnet® Recognition. The nurse knows that compared with other hospitals, Magnet® hospitals have which direct effect on client care? Better patient outcomes Longer patient stays Improved job satisfaction scores Higher nurse retention
Better patient outcomes Explanation: Magnet® hospitals have better patient outcomes than facilities without the recognition. Magnet® hospitals have higher nurse retention and job satisfaction scores, but these do not have a direct effect on client care. Magnet® hospitals have shorter, not longer, patient stays.
A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept? Forgiveness Efficient interactions Effective use of language Naturalness
Efficient interactions Explanation: The statement reflects efficient interactions. One of the most direct ways to facilitate efficient user interaction is to that minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user. Effective use of language involves the use of concise, unambiguous language with terminology that is familiar and meaningful to the end users in the context of their work.
A client is admitted to the intensive care unit. Which way can the nurse decrease sensory overload in this unit? Tell the client to turn on the call light if there are questions. Explain unfamiliar procedures to the client. Give the client a tour of the unit. Assure the client that the nurses will take care of everything.
Explain unfamiliar procedures to the client. Explanation: Severe sensory alterations can occur when a client is admitted to a health care agency, especially in certain areas such as intensive care units (termed intensive care unit [ICU] psychosis). By explaining unfamiliar procedures the client will have a better chance of avoiding sensory overload. In most cases a client in an ICU will be too ill for a tour. The client should be instructed to use the call light, but preventative explanation will be most effective.
Which nursing intervention would best demonstrate evidence-based practice in maternal-child health care? Decentralizing care to allow clients to be closer to home Family-centered pediatric care Placing adults and children with similar diseases on the same unit Minimizing parental interaction with preterm infants
Family-centered pediatric care Explanation: Evidence-based practice has become the standard that nurses are to strive for in caring for their clients. By involving the family in caring for ill children, the child and the family are better served and have improved outcomes. Parental interaction is encouraged for preterm infants to foster bonding. Children and adults need to be separated on inpatient units to ensure that the caregivers have a clear understanding of each client's needs, since children are not small adults. Centralized care has proved to be most beneficial to client outcomes by providing resources and specialists in one location.
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? Incentivizing health care workers to utilize hand hygiene Encouraging visitors to adhere to isolation precautions Limiting visitors to family members over the age of 18 Revising the facility's infection control protocols
Incentivizing health care workers to utilize hand hygiene Explanation: Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene. Revising the agency's infection control protocols is not nursing centered. Encouraging visitors to adhere to isolation precautions is important but does not affect the immediate surroundings and personal space that can cause a contaminated work environment. Limiting visitors to family members over the age of 18 is not client-centered care and will not decrease transmission of pathogens.
The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? Quality assurance Quality improvement Magnet status Peer review
Quality assurance Explanation: Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven, continuous process focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy. Magnet status is awarded by the American Nurses Credentialing Center, recognizing health care organizations for their excellence in nursing.
A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? Assess the temperature, blood pressure, and check for blood in the urine. Then stop the transfusion. Stop the transfusion, notify the blood bank, and administer antihistamines. Slow the transfusion and monitor the client's vital signs. Stop the transfusion, infuse normal saline solution, and call the physician.
Stop the transfusion, infuse normal saline solution, and call the physician. Explanation: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions should not be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.
A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to 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 protecting the nurse and the hospital from litigation following up on the incident with other members of the care team gauging the nurse's professional performance over time
identifying risks and ensuring future safety for clients Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action and they are not commonly used to communicate within the interdisciplinary team.
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? protecting the nurse and the hospital from litigation gauging the nurse's professional performance over time identifying risks and ensuring future safety for clients following up the incident with other members of the care team
identifying risks and ensuring future safety for clients Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.
The nurse's unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught? the percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity the quality of teaching by the nurses who educate the acute MI clients on the telemetry unit the clients' perception of the quality of the discharge instructions the amount of education the acute MI clients received on the telemetry unit
the percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity Explanation: The unit council needs to assess the number of clients diagnosed with an acute MI on the telemetry unit who were actually taught about resuming sexual activity. The unit council needs to identify the number of clients who were taught, not the quality of the teaching. Only education about resuming sexual activity is pertinent to this performance improvement study. The nurses' assessment of the quality of client education isn't pertinent to this study either.
The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next? Submit the safety report to the appropriate department within the facility so that it can be reviewed. File the safety event report in the appropriate file and document in the nurse's notes the date and time that it was filed. Make a copy of the safety event report for the client. Place the safety event report in the client's medical record for future reference.
Submit the safety report to the appropriate department within the facility so that it can be reviewed. Explanation: When an adverse event occurs, a safety event report should be filed and submitted according to facility policy. Safety event reports should not become a part of the client's medical record, nor should they be mentioned in documentation or copied and given to the client.
An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate? "It involves working primarily with computers and programming codes." "It is a specialty that deals with online client educational programs." "It combines nursing science with information management and analytical sciences." "It refers to the use of the electronic health record."
"It combines nursing science with information management and analytical sciences." Explanation: The ANA defines nursing informatics (NI) as "the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice." It is more than just working with computers or the electronic health record (although this is the core of informatics practice). Client education can be one component of a clinical information system with which nursing informatics may be involved.
A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management? "We can discipline the ED staff for not getting the clients to the ICU fast enough." "We can review ED staffing to see if shortages affect ICU admission." "We can use statistics gathered in the ED during triage to determine the average time for admission to the ICU." "We can collaborate with staff from the ED and the ICU to formulate strategies and implement change."
"We can discipline the ED staff for not getting the clients to the ICU fast enough." Explanation: Using statistics and other indicators, such as ED staffing information, to develop a change strategy is part of performance management. Disciplining staff doesn't reflect a strategy based on indicators. Collaborating with staff from other areas results in performance improvement, not performance management.
A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care? Another registered nurse with critical care certification Another staff nurse from the medical-surgical unit One of the staff critical care physicians Another nurse manager
Another registered nurse with critical care certification Explanation: Peer review is the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. Therefore, another registered nurse who is certified in critical care would be appropriate to evaluate a critical care nurse certified in critical care. A nurse manager and a critical care physician are at a higher level in the hierarchy than a staff nurse certified in critical care. A staff nurse without certification in critical care would also not be appropriate to evaluate a nurse with this certification.
A staff nurse on a busy pediatric unit would like to function effectively in the role of a leader. Which action would the nurse employ to be a leader? Ask the nursing administration for the authority to make decisions that will affect the staff. Follow unit and hospital policy in daily situations. Tell the staff on the unit how to do their job effectively based on current research and relevant experience. Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills.
Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills. Explanation: A leader does not have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager's formal power and authority within the organization are detailed in the job description. An autocrat is not interested in guiding or encouraging staff or in being an effective role model. A manager derives authority by virtue of the position within an organization.
A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? Meet with the new nurse and the primary nurse and help set up an additional week of orientation. Meet with the new nurse and question the new nurse about deficits in performance. Explain to the primary nurse that a 6-week orientation is standard. Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process.
Meet with the new nurse and the primary nurse and help set up an additional week of orientation. Explanation: The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation does not mean that a nurse is not competent or that there are deficits in performance. Although a 6-week orientation may be standard, orientation periods should be individualized to meet the needs of the staff as well as provide the best client outcomes. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete the orientation as efficiently as possible.
A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first? Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. Document the medication error and completion of the variance report in the client's chart and notify the physician. Alert the charge nurse that they made a medication error. Check the second client's identification and administer the remaining medication to him.
Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. Explanation: The nurse should return to the room to check the client's identification against the medication administration record. If there was an error, the nurse should then complete a variance report in accordance with facility policy and check the remaining medication before administering it to the second client. The client record shouldn't include documentation of a completed variance report. The nurse should inform the charge nurse of the error after confirming that an error has been made.
The second step in implementation of evidence-based practice includes systematic review. To complete a systematic review of the literature, what must the nurse do? Ask a question about a clinical practice. Recommend best practices for client care. Summarize findings from multiple studies that are related to a particular nursing practice. Provide a statical analysis for studies.
Summarize findings from multiple studies that are related to a particular nursing practice. Explanation: A systematic review suggests that the nurse has reviewed multiple studies regarding a particular nursing practice question or topic. Asking the question about a clinical practice would come in the first step. A recommendation for best practice comes after synthesizing all of the data collected by the systematic review. Meta-analysis is concerned with doing a statistical analysis across studies.
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? Transfer report Nurse's shift report Incident report Telemedicine report
Incident report Explanation: 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.
What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered? Nurses now spend time looking up the best way to give nursing care. Nursing care now uses EBP as a means of ensuring quality care. Nurses now have to take part in research. Nursing care now incorporates research studies into client care.
Incident report Explanation: 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.
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 has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers.
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care are examples of source-oriented recording.
