NURS 121 PrepU Chapter 19: Documenting and Reporting

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?

"It will allow for us to see the client and possibly increase client participation in care."

The health care provider tells the client, "You are experiencing an MI," and leaves the room. The client asks the nurse what an MI stands for. What response by the nurse is most accurate?

"Myocardial infarction."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?

"The clients' medical records are an obstruction to research and education."

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

0000

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

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.

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?

Assess the triggers from the data.

Which note includes all elements of a SOAP note?

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

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

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

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

Which practice should the nurse adopt when commmunicating and documenting electronically?

Include precise measurements in documentation rather than approximations

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

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 Keeping record of people who have access to clients' records

In SBAR, what does R stand for?

Recommendations

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.

At change of shirt, the nurse is presenting information about a client to a colleague that is coming on shift. The nurse is performing what nursing action?

Reporting

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.

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

Reviewing the agency's list of approved abbreviations Locating clients' files within an electronic health record system Identifying the form appropriate to be used for documenting

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take?

Revise the plan of care.

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 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.

A nurse is documenting care for an older adult client who is recovering from a mild stroke. Which documentation entry(ies) follows the recommended guidelines for communicating and documenting client information? Select all that apply.

The client rates pain as 2 compared to a 7 yesterday. Radial pulse 72 beats/min, strong and regular.

The following statement is documented in a client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

A nurse is documenting care for clients in a hospital setting. Which documenting errors may potentially increase the nurse's risk for legal problems? Select all that apply.

The content is not in accordance with professional standards. There are lines between the entries. Dates and times of entries are omitted.

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 nurse has begun a new role on a high acuity unit where clients' health status often change rapidly. What practice should the nurse adopt to maximize the accuracy of documentation?

Use point-of-care documentation whenever possible

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

a client who is homebound and needs skilled nursing care

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

a referral.

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

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.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document.

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

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

urine output 100 ml

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?

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

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?

Translators may need additional explanations of medical terms.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records?

those directly involved in the client's care

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit.

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them.

"I don't feel well. I've been urinating often, and it burns when I urinate." Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. Fever, possible urinary tract infection Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?

"I think the client would benefit from intravenous furosemide."

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?

"I will have to review the policy that determines what procedure is in place for client access."

Which are purposes of documentation in health care records? Select all that apply.

To facilitate quality To serve as a financial record To support decision analysis To assist with clinical research