NUR 209 Ch. 16 Documenting, Reporting, Conferring, and Using Informatics (Fundamentals of Nursing)

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? (page 349)

1 Unit of glucose

Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? (page 343)

A client has asked a nurse if he can read the documentation that his physician wrote in his chart

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? (page 357)

A flow sheet

When documenting information in a client's medical record, what should the nurse do consistently for each entry? (page 342)

Sign each entry by name and title.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? (page 358)

a client who is homebound and needs skilled nursing care

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: (page 246)

interpretation of data.

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? Page 353)

Progress notes

The parent of a 33 year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate? (page 361-362)

Ask the client if information can be given to the parent.

A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient 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? (page 353)

Problem-oriented method

A nurse manager of a physician's office is responsible for obtaining signed authorizations for releasing patient information to third parties. In which situations would the nurse not need an authorization from the patient? (Select all that apply.) (page 344)

Reporting the incidence of an infectious disease to Center for Disease Control Releasing a medical record to the court when a nurse is being sued for negligence Facilitating organ donation of a deceased patient Providing statistics related to the use of a dangerous piece of equipment