NUR 313 Documentation, Reporting, Conferring

A nurse uses the ISBARR format to report the deteriorating mental status of a patient using morphine via a patient-controlled analgesia pump (PCA) for postoperative pain. Place the following nursing statements related to this call in the correct ISBARR order. A. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." B. "Mr. Sanchez has been difficult to arouse, and his mental status has declined over the past 12 hours." C. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." D. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." E. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." F. "I suggest a decrease in the dose of morphine."

1. D. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." 2. A. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." 3. E. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." 4. B. "Mr. Sanchez has been difficult to arouse, and his mental status has declined over the past 12 hours." 5. F. "I suggest a decrease in the dose of morphine." 6. C. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." The order for ISBARR is: Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read-back.

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? A. Client's record and occurrence report B. Occurrence report and critical pathway C. Critical pathway and care plan D. Care plan and client's record

A. Client's record and occurrence report An occurrence report should be completed when a planned intervention is not implemented as ordered. The incident, with actions taken by the nurse, should also be included in the client's record. Critical pathways and care plans are not places to document occurrences.

Which practice should the nurse adopt when commmunicating and documenting electronically? A. Seek client permission before posting information on social media B. Avoid using client names if emailing information on an unencrypted network C. Include precise measurements in documentation rather than approximations D. Avoiding using names of health care providers

C. Include precise measurements in documentation rather than approximations Precise measurements and times must be used whenever possible. Client information should never be sent over an unencrypted email network and social media posts should never include any references to clients, regardless of permission. It is appropriate to use health care providers' names in documentation.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? A. Disclosing client health information for research purposes after obtaining permission from the client's health care provider B. Releasing the client's entire health record when only portions of the information are needed C. Submitting a written notice to all clients identifying the uses and disclosures of their health information D. Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

C. Submitting a written notice to all clients identifying the uses and disclosures of their health information Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the health care provider's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

A nurse receives a prescription for an analgesic for a patient who has compound fractures of the tibia and fibula. What schedule will the nurse use to administer the medication? Electronic health record (EHR) Health care provider order sheet 8:00 AM: Hydromorphone 1 mg IV every 2 hours PRN severe pain. -S. Jones, MD A. When the patient requests it B. Every 2 hours on the even hours C. Daily, every 2 hours D. As requested, 2 hours or more after the last dose

D. As requested, 2 hours or more after the last dose PRN means "as needed." The nurse teaches the patient that the medication may be requested every 2 hours to treat pain. If pain occurs before 2 hours elapses, the nurse provides comfort measures and collaborates with the health care provider for a change in prescription.

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? A. "Any information that can identify a person is considered a breach of client privacy." B. "You may continue to post about a client, as long as you do not use the client's name." C. "All aspects of clinical practice are confidential and should not be discussed." D. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

A. "Any information that can identify a person is considered a breach of client privacy." Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? A. "It will allow for us to see the client and possibly increase client participation in care." B. "It will let me see everything that has been done and things that need to be done." C. "It makes our client feel like we care, especially if we start the day off with a clean room." D. "It will give me a better sense of what my workload will be today."

A. "It will allow for us to see the client and possibly increase client participation in care." Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A. A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart. B. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. C. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. D. A client who resides in Indiana has required hospitalization during a vacation in Hawaii.

A. A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart. Among the provisions of HIPAA are clients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA.

An emergency department nurse is caring for four clients. Which client would the nurse suspect as using displacement as a defense mechanism? A. A client with a fractured hand after punching a wall B. A client with a traumatic amputation refusing to look at the extremity C. An adult client crying and stating, "I want my mommy." D. A client on dialysis who missed two appointments in one week.

A. A client with a fractured hand after punching a wall The defense mechanism of displacement transfers the emotional response from one person to another person or object. The client who punched a wall may have used displacement by punching a wall and not a person. Refusing to look at a traumatic injury can be denial. The adult client crying is demonstrating regression. The client who missed two dialysis appointments is not demonstrating displacement.

The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate? A. Assess the triggers from the data. B. Document the findings on an occurrence report. C. Provide a comprehensive written report to the client ombudsperson. D. Repeat the minimum data set in 2 weeks.

A. Assess the triggers from the data. Once the minimum data set is complete, it will identify elements or triggers for issues that the resident either has or is at risk for developing. The information should not be documented on an occurrence report, as it is not is a comprehensive written report required to be sent. There is no need to complete the minimum data set in 2 weeks unless the resident has a significant change in condition.

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? A. Calling the client information desk to find out the room number of the family member B. Finding the emergency medical technicians who transported the family members and inquiring about the injuries C. Asking the emergency department nurse for information on the family member D. Accessing the electronic health record of the family member to find out extent of injury

A. Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format? A. Charting by exception B. PIE C. Narrative notes D. SOAP notes

A. Charting by exception Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in CBE narrative-style notes. The question is asking about a pregnant woman with hypertension. This is not an expected situation for a typical pregnant woman, so CBE is a way to document this situation so that it will be immediately seen in the documentation. The PIE (Problem, Intervention, and Evaluation) charting method is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified). This would not be the best method of documentation if the nurse wanted the documentation to stand out regarding the client's condition. Narrative notes address routine care, normal findings (findings that do not call for changes in the plan of care), and client problems identified in the plan of care. SOAP notes (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes, focusing primarily on the client and any identified problems. This could be a possible method of documentation for the question asked, but CBE is a better method.

When maintaining health care records for a client, the nurse knows that a health care record also serves as a legal document of evidence. What should the nurse do to ensure legally defensible charting? A. Ensure that the client's name appears on all pages. B. Leave spaces between entries and signature. C. Use abbreviations wherever possible. D. Record all facts and subjective interpretations.

A. Ensure that the client's name appears on all pages. The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and should not use abbreviations wherever possible. The nurse should record all the facts, but not any subjective interpretations, to ensure that the document is legal evidence.

Which are high-risk errors in documentation? Select all that apply. A. Inadequate admission assessment B. Failure to document completely C. Charting in advance D. Batch charting E. Falsifying client records

A. Inadequate admission assessment B. Failure to document completely C. Charting in advance E. Falsifying client records Although batch charting is not ideal, it is not considered a high-risk error made in documentation. High-risk errors include falsifying client records, charting in advance, failure to record changes in a client's condition, failure to document that the health care provider was notified when a client's condition changed, inadequate admission assessment, incomplete documentation, and failure to follow agency standards or policies on documentation.

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? A. Incident report B. Nurse's shift report C. Transfer report D. Telemedicine report

A. 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.

A nurse is using the PIE format to document care of a patient who is diagnosed with type 2 diabetes. What information does the nurse need to complete documentation in this format? A. Patient problem list B. Narrative notes describing the patient's condition C. Overall trends in patient status D. Planned interventions and patient outcomes

A. Patient problem list In the PIE format, patient problems are numbered; documented in the progress notes; worked up using the Problem, Intervention, Evaluation (PIE) format; and evaluated each shift. Resolved problems are dropped following the nurse's review. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using charting by exception (CBE). Planned interventions and patient-expected outcomes are the focus of the case management model.

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. A. Showing the provider the trends from baseline to present in blood pressure B. Informing the provider of the client's present heart rate of 116 beats/min C. Faxing the results of blood chemistry levels to the provider's office D. Writing the hemoccult result on a piece of paper and leaving it at the desk Placing a note on the computer terminal with the client's name and information

A. Showing the provider the trends from baseline to present in blood pressure B. Informing the provider of the client's present heart rate of 116 beats/min C. Faxing the results of blood chemistry levels to the provider's office Reporting to the primary care provider can occur face-to-face, by telephone, by text messaging, or, in some settings (e.g., long-term or home care), by fax. Placing a note on a computer terminal with client information or writing the hemoccult results on a piece of paper and leaving it at the desk is a violation of the Health Insurance Portability and Accountability Act because the information is visible and accessible to anyone passing by. The other answers are appropriate ways to communicate client information to a health care provider while protecting the client's confidentiality.

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? A. Source-oriented B. Problem-oriented C. PIE charting D. Charting by exception

A. Source-oriented A source-oriented record is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

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? A. The health care provider's assessment and treatment B. Results of laboratory and diagnostic studies C. Nursing documentation and plan of care D. Information from other members of the health care team

A. The health care provider's assessment and treatment The medical history, physical examination, and progress notes record the findings of health care providers as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment. The laboratory results will be in a different section of the health record and not typically in the medical history and treatment plan. Nursing documentation will be in the nursing section. Information from the other members of the health care team is found in the progress notes.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? A. Write a narrative note in the designated nursing section. B. Place the narrative note chronologically after the respiratory therapist's note. C. Review the laboratory results under the health care provider section. D. Use a critical pathway to document the physical assessment.

A. Write a narrative note in the designated nursing section. Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the health care provider section. Critical pathways are not used to document physical assessments.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? A. a client who is homebound and needs skilled nursing care B. a client whose rehabilitation potential is not good C. a client whose status is stabilized D. a client who is not making progress in expected outcomes of care

A. a client who is homebound and needs skilled nursing care 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, and the client is making progress in expected outcomes of care.

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? A. charting by exception B. narrative notes C. problem, intervention, and evaluation note D. FOCUS data, action, and response note

A. charting by exception The team would most likely suggest the use of charting by exception, which is an abbreviated form of documentation. Narrative notes are time-consuming to write and require much reading to learn about a specific problem. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a FOCUS can reflect a possible problem area but does not need to be an actual problem.

What does the nurse recognize as purposes of the electronic health record? Select all that apply. A. documenting continuity of care B. qualifying health care providers for government funds C. ensuring client safety D. facilitating health education and research E. defending health care personnel during practice lawsuits

A. documenting continuity of care B. qualifying health care providers for government funds C. ensuring client safety D. facilitating health education and research The electronic health record provides an avenue to document continuity of care, qualify health care providers for government funds, ensure client safety, and facilitate health education and research. It can provide evidence during practice lawsuits, however, that is not the purpose of the electronic health record.

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? A. "The hospital owns your records and does not have to allow you access while you are a client here." B. "I will have to review the policy that determines what procedure is in place for client access." C. "Let me open up the computer access so that you can see what information is of interest to you." D. "You may not understand all of the information and it will confuse you so I will help you decipher it all."

B. "I will have to review the policy that determines what procedure is in place for client access." Clients have the right to see their own medical records and request changes to documentation that may be in error. Most facilities have a policy in place for the client to obtain medical records and the nurse should ensure that the policy is followed by being familiar with that policy prior to giving the client free access to the record. The nurse should not demean the client by assuming that the information may be confusing. The nurse should not allow the client access to the computer while using the nurse's password or login information. While the hospital maintains responsibility for the record, the client has the right to see it.

A nurse receives a call from a friend requesting information on her mother-in-law who was just admitted to the hospital. How does the nurse best respond? A. "You shouldn't be asking me to do this. I could be fined or lose my job for disclosing this information." B. "I'm sorry; per privacy laws, I can't give out patient information—even to my best friend or a family member." C. "Because of HIPAA, you could get in trouble for asking for this information unless you are authorized by the patient to receive it." D. "Why are you asking? Are you extremely worried?"

B. "I'm sorry; per privacy laws, I can't give out patient information—even to my best friend or a family member." The nurse should immediately clarify they must adhere to HIPAA laws to protect patient privacy and confidentiality. Mentioning penalties for breaches of privacy sidesteps the need to clearly introduce or reinforce the policy. It may be appropriate to ask the friend about her concerns, only after clarifying privacy laws.

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? A. Immediately delete the incorrect documentation. B. Create an notation with a correction. C. Contact information technology (IT) staff to make the correction. D. Contact the health care provider.

B. Create an notation with a correction. If the nurse is using an EMR and the documentation cannot be changed, an notation will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client.

A graduate nurse and preceptor are discussing protected health information (PHI) and HIPAA laws. The preceptor explains that PHI can be released without the patient's signed authorization in which situations? Select all that apply. A. News media are preparing to report on a patient who is a public figure. B. Data are needed for the tracking and notification of disease outbreaks. C. Protected health information is needed by a coroner. D. Child abuse and neglect are suspected. E. Protected health information is needed to facilitate organ donation. F. The sister of a patient with Alzheimer's disease wants to help provide care.

B. Data are needed for the tracking and notification of disease outbreaks. C. Protected health information is needed by a coroner. D. Child abuse and neglect are suspected. E. Protected health information is needed to facilitate organ donation.

When documenting a dressing change to a residual right limb, the nurse erroneously documents that the dressing change was performed on the left leg. How will the nurse most appropriately correct the documentation? A. Use white correction fluid to cover the error and neatly write over the correction B. Draw a single line through the error, write "mistaken entry," add correct information, and date and initial C. Blacken out the error with permanent marker and rewrite the note in the next available space D> Leave the entry in place, create a correctly written entry below, and cite the charting error above

B. Draw a single line through the error, write "mistaken entry," add correct information, and date and initial The nurse should not black out, use erasers or correcting fluids to correct documentation, or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered, the nurse should mark the entry "mistaken entry," add the correct information, and date and initial the entry. If the nurse records information in the wrong chart, the nurse should write "mistaken entry—wrong chart" and sign off. The nurse should follow similar guidelines in electronic records.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. A. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards B. Obscuring identifiable names of clients and private information about clients on clipboards C. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D. Keeping record of people who have access to clients' records E. Making the names of clients on charts visible to the public

B. Obscuring identifiable names of clients and private information about clients on clipboards C. Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public D. Keeping record of people who 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; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

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? A. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. B. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. C. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. D. The nurse sends or directs someone to take action in a specific nursing care problem.

B. 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.

A new home health nurse and preceptor are reviewing charting for a patient with advanced lung cancer who receives Medicare benefits. When reviewing a draft of the new nurse's documentation, which statement will the preceptor correct? A. Explained to family that irregular respirations or agitation may occur when the patient is actively dying B. The patient seemed in better spirits and reported going out for ice cream with his family yesterday C. Stage 3 pressure ulcer dressing on sacral area is dry and intact; due to be changed tomorrow D. Performed medication reconciliation with focus on pain management and anticoagulation

B. The patient seemed in better spirits and reported going out for ice cream with his family yesterday To receive Medicare services, the patient must be homebound, still needs skilled nursing care, or that the patient is dying, among others. Leaving the home for ice cream may interfere with home care benefits.

When chronic illnesses and disabilities are present, individuals benefit most from activities that: A. help them eat well. B. help them maintain independence. C. preserve their social interactions. D. accomplish financial stability.

B. help them maintain independence. Although their chronic illnesses and disabilities cannot be eliminated, adults can benefit most from activities that help them maintain independence and achieve an optimal level of health. The other answers, while beneficial, are not as helpful.

A health care provider has been urgently paged to another unit and asks a nurse to enter a pain medication prescription for their patient in the electronic medical record. Which response by the nurse is most appropriate? A. "Thank you for taking care of this; I'll be happy to enter a verbal order into the electronic health record." B. Get a second nurse to listen to the order, write the order on the health care provider order sheet, and ensure both nurses sign it. C. "I'm sorry; verbal orders can only be accepted in an emergency. Please enter this quickly before leaving this unit." D. Try calling another resident for the order or wait until the next shift.

C. "I'm sorry; verbal orders can only be accepted in an emergency. Please enter this quickly before leaving this unit." In most facilities, health care providers may only issue verbal orders in an emergency. The provider is present but finds it impossible, due to the situation, to write or enter the order in the electronic health record. Calling another health care provider or waiting until the next shift would be inappropriate; the patient should not have to wait for the pain medication, and a provider is available who can quickly write/enter the order.

A nurse is caring for a postoperative patient who has a prescription for morphine 2 mg IV every 3 hours. Which examples documenting pain management best reflect recommended guidelines? Select all that apply. A. 6/12/25 0945 Morphine 2 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN. B. 6/12/25 0950 Morphine 2 mg administered IV. Patient appears to be comfortable. M. Patrick, RN. C. 6/12/25 1015 Administered morphine 2 mg IV at 0945, patient reporting pain as 2 on a scale of 1 to 10. M. Patrick, RN. D. 6/12/25 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN E. 6/12/25 0945 Morphine IV 2 mg will be administered to patient every 3 hours. M. Patrick, RN F. 6/12/25 0945 Patient states they do not want pain medication despite return of pain. After discussion, patient agrees to try morphine 2 mg IV. M. Patrick, RN

C. 6/12/25 1015 Administered morphine 2 mg IV at 0945, patient reporting pain as 2 on a scale of 1 to 10. M. Patrick, RN. D. 6/12/25 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN F. 6/12/25 0945 Patient states they do not want pain medication despite return of pain. After discussion, patient agrees to try morphine 2 mg IV. M. Patrick, RN The nurse should enter information in a complete, accurate, concise, current, and factual manner, indicating the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes, derogatory terms, and judgments such as "response to pain appears to be exaggerated" or "seems to be comfortable." Stating that medication will be given does not document care given; this prescription/intervention belongs in the plan of care.

The nurse on an oncology unit is caring for a patient admitted for dyspnea and wheezing. What is most important for the nurse to include in the change-of-shift report to the oncoming nurse? A. Partial bath was given B. Patient received physical therapy C. CT scan revealed a mass in the right lung D. Patient did not eat lunch today

C. CT scan revealed a mass in the right lung The nurse's shift or handoff report includes basic identifying information about the patient. The outgoing nurse includes the patient's current health status and changes during their shift, response to nursing and medical therapy, pertinent monitoring and assessment findings (e.g., lab and radiology data), pain management, changes in orders (medications, intravenous fluids, diet, and rationale), upcoming/ongoing tests and procedures, and instructions for these, such as NPO after midnight, unfilled prescriptions for the next shift to follow up on, and patient and family questions, concerns, and needs.

Which are appropriate actions for protecting clients' identities? Select all that apply. A. Orient computer screens toward the public view. B. Ensure that clients' names on charts are visible to the public. C. Document all personnel who have accessed a client's record. D. Place light boxes for examining X-rays with the client's name in private areas. E.Have conversations about clients in private places where they cannot be overheard.

C. Document all personnel who have accessed a client's record. D. Place light boxes for examining X-rays with the client's name in private areas. E.Have conversations about clients in private places where they cannot be overheard. Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of client confidentiality.

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? A. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. B. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. C. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. D. 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.

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

A client informs the nurse that they have a well-paying job but that it is demanding and causes a great deal of anxiety. What statement made by the client indicates that the client has a beneficial coping mechanism to deal with anxiety produced by this situation? A. " Everyone feels sorry for me, and I find comfort in that." B. "I am going to confront my manager about the amount of stress in this job." C. "I am going to have to start taking medication for this anxiety." D. "I am actively seeking job opportunities in a less stressful environment."

D. "I am actively seeking job opportunities in a less stressful environment." The person may respond by limiting his emotional response, taking direct action to solve a problem, or using defense mechanisms. In this case, seeking another job is a clear example of direct action. Medications are not considered to be coping mechanisms. Confrontation and pity are less likely to bring about a positive resolution to the client's stressor.

A patient being discharged from the hospital asks to receive a copy of their medical record. What information will the nurse give the patient? A. "I'm sorry, but patients are not allowed to copy their medical records." B. "I can make a copy of your record for you right now." C. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." D. "I'll check with the medical records department to determine how you request a copy."

D. "I'll check with the medical records department to determine how you request a copy." According to HIPAA, patients have a right to view and receive a copy of their health record; update their health record; get a list of the disclosures a health care institution has made, independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records.

A nurse is looking for trends in a postoperative patient's vital signs. In which part of the electronic health record will the nurse find this information? A. Admission sheet B. Admission nursing assessment C. Progress notes D. Graphic record

D. Graphic record While one set of vital signs may appear on the admission nursing assessment, the best place to find sequential recordings demonstrating a pattern or trend is the graphic record. The admission sheet and flow sheet do not include ongoing vital sign documentation.

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? A. SOAP B. narrative C. focus D. charting by exception

D. charting by exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. In the scenario, the BP is abnormal and is documented by exception. The other types of documentation are not being represented in this scenario.

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? A. data base B. problem list C. plan of care D. progress notes

D. 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.