PrepU Chapter 4

If the nurse makes an error while documenting findings on a client's record, the nurse should

draw a line through the error, writing "error" and initialing.

The nurse is documenting client care. Which nursing assessment note would be most appropriate?

"Client voices concerns about being able to change abdominal dressings at home."

During a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?

-A description of a large bruise on the client's thigh -The client's weight -The presence of a lump in the client's breast discovered on palpation

A nurse is currently in the assessment phase of the nursing process with a client. Which pieces of information should the nurse document during this phase? Select all that apply.

-Physical assessment data -Nursing history -Information provided by the client

Which pieces of information should the nurse document during the assessment phase of the nursing process? Select all that apply.

-Physical assessment data -Nursing history -Information provided by client

Which assessment is most likely performed when a client is admitted to the hospital?

Comprehensive

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?

Evidence in a situation of wrongdoing

During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance?

Facility level

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?

Focused

The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation?

Hyperactive bowel sounds are heard in all four quadrants.

When charting by exception is used in a health care agency, the most important aspect of this method is what?

Identifying the standards and norms for the institution

Examples of objective data include all the following except:

Itchy skin

When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution.

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

Meaningful use of electronic health records

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?

Use phrases instead of sentences to record data.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Verify the data by having another nurse come in to perform the percussion.