PrepU Chap 10

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

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

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."

A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. 1"I don't feel well. I've been urinating often, and it burns when I urinate." 3Fever, possible urinary tract infection 2Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.

1"I don't feel well. I've been urinating often, and it burns when I urinate." 2 Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3Fever, possible urinary tract infection 4Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edematous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"?

FOCUS

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting

The nurse has paged a client's primary care health care provider in response to the client's low blood pressure reading. When returning the nurse's page, the health care provider has asked the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?

Write "T.O." after the order and write out the health care provider's name and the nurse's name.

The nurse is caring for a client in the intensive care unit who must be administered multiple medications. The client is often unresponsive and cannot offer information during assessment. When administering the medication, which step by the nurse is most important to avoid confusion and ensure safety?

Scan the client's wristband prior to administering medication to verify it is the correct client and correct medication.

A nurse is making a home visit to a client for the first time. The nurse is documenting assessment information on a laptop computer as each aspect of the assessment is completed. The nurse is using:

point-of-care documentation.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback?

vulnerability to legal liability since nurse's safe, routine care is not recorded