THEORY WEEK 6

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

Sign each entry by name and title.

A client made a formal request to review their medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

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."

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 sugar is 250, and I wondered if you would like to adjust the sliding scale insulin."

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

"I know that you are anxious, but removal will be painless and the IV location needs to be changed."

A nurse is caring for an older adult client who has just died in a hospice unit. The child of the client arrives and asks, "Can I please stay and sit at the bedside? I really wanted to be here so they did not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

The unlicensed assistive personnel (UAP) has taken vital signs. The nurse is currently logged into the electronic health record, and the UAP needs to document the vital signs. How does the nurse the UAP to document?

"I will log out of the electronic health record and you can log in to document."

The nurse has arranged to start an V line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?

"I will start an IV that will add fluids directly to the blood stream."

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

"Is that a new shirt you're wearing?"

A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse?

"Tell me more about how it feels to eat with your family."

A female client reports to her primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that she does not want to take the test and feels she should instead continue with the medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

"Tell me more about how you are feeling."

A nurse visits a female victim of sexual assault for the fourth visit. The client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?

"Tell me more about the aspects that make you feel as if it happened yesterday."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position."

A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client andously inquires if he had a heart attack. What should be the nurse's reply?

"The physician wants to monitor you and control your pain."

A nurse is examining a 3-year-old child with conjunctivitis. During the examination, the child starts crying and refuses to sit still. Which statement is appropriate for the nurse to tell the child?

"Would you like to see my flashlight?"

The student nurse is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?

"You said that you do not smoke, but you have an open package of cigarettes in your pocket."

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor."

A client who is bedridden is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as:

0800 and 2000

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

1600: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

A nurse needs to complete and assessment and vital signs on a client who has Alzheimer's disease. How should the nurse approach this client to gain cooperation? (Select all that apply.)

Approach the client from the front. ,Use the client's name, Smile and maintain eye contact.

A nurse is interviewing an American Indian client who has come to the clinic for a follow- up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue with the interview.

During the admission phase, the nurse is required to assess the client and collect information for the data base. The nurse can also delegate some part of the work to other ancillary staff. Which of the following can the nurse delegate to the other staff?

Client's physical assessment

A client with medically complicated pregnancy has expressed frustration about the disparities in advice and treatment that the client has received at various sites over the past several months. How can the nurse best ensure that there is continuity in the care that the client receives?

Communicate clearly and frequently with other care providers.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. What is the best technique for recording the error made in documentation?

Cross out the incorrect statement with a single line and place nurse's initials above it.

A nurse is taking a note of a client's belongings by recording their details in the medical record. How should the nurse best describe a client's ring?

Describe the type of metal and stones in the ring.

A nurse is caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family. Which intervention is most appropriate?

Encourage family discussions of feelings.

An elderly female client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO". Based on this order, what action should the nurse take?

Ensure that the client does not eat or drink anything

A nurse is documenting the plan of care for a client with AIDS. Which of the following is most important when documenting the plan of care?

Ensure that the client's medical record and nursing interventions are written.

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

Ensure that the client's name appears on all pages.

A nurse is caring for a client with a fracture in his hand. How should the nurse assist the client to change his clothes?

Gather the garment and work it up and over the body.

A nurse is caring for a client at the local health care facility. What ensures that the HIPAA legislation is implemented at the facility?

I Place light boxes for examining x-rays with the client's name in private areas.

A nurse caring for a client who is being treated by three physicians uses the source- oriented format for documentation. What are the benefits of using this format of documentation?

Information is documented in separate forms by each health care personnel.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings.

A client has been admitted to the health care facility for less than 24 hours for observation. The client has a gold ring, watch, reading glasses, and other personal belongings. What care should the nurse take with regard to these objects?

Keep the client's belongings secured in a locker.

A client admitted to a health care facility uses a walker for support. What is the nurse's responsibility with regard to the walker when admitting the client to the nursing unit?

Mark the client's walker with a large, easily readable label.

A nurse charting the medical record for a client knows that which form of charting involves writing information about the client and client care in chronological order?

Narrative charting

Once a client is admitted and all the admission data are callected, the nurse is expected to develop an initial plan for the client's care. By what point after admission should the nurse develop the plan?

No later than 24 hours

A nurse is working with a client who is in postoperative day 2 following a total knee replacement. The client has briefly mobilized using a wheeled walker and with the assistance of the physical therapist. However, the client is reluctant to progress further with mobilization for fear of injuring herself. In response to this, the nurse has liaised with the physical therapist to create a plan of care that creates specific goals for the client's mobility. In doing so, this nurse has exemplified what role?

Nurse as collaborator

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports?

O Come prepared with material required to take notes.

A nurse who has been practicing for three decades has seen significant changes in the roles that clients are expected to perform in the course of their care. What is a role that clients are normally expected to perform while they are receiving care?

Participate actively in the planning and execution of the ir care.

The nurse makes an erroneous entry into the written health record. What is the appropriate nursing action?

Place one line through the entry, and initial.

A nurse is caring for a client who is to be transferred to another unit in the same facility. Which of the following is a responsibility of the nurse during the transfer of the client?

Provide a written review of the client's status.

A nurse is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPNLVN). Which tasks are appropriate to delegate to the LPNLVN? (Select all that apply.)

Reinforce a post-surgical abdominal dressing. , Administer oral aspirin and lisinopril to the client with hypertension. ,Insert a nasogastric tube in a client with absent bowel sounds.

A nurse is caring for a client with myasthenia gravis. The client is having difficulty forming words and his tone is nasal. Which communication strategy is an effective one for this client?

Repeat what the client has said to verify the meaning.

A health care facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details?

SOAP charting

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting

An elderly client with a tracheostomy is to be discharged from a health care facility. Which of the following extended care facilities should the nurse suggest to the client for continued care until complete recovery?

Skilled nursing facility

A nurse working with an experienced licensed practical/vocational nurse (LPN/LVN) delegates the task of administering oral medications to a team of clients. The nurse observes the LPNLVN document a client's medication administration before entering the client's room. What is the most appropriate action of the nurse?

Stop the LPN/LVN immediately and discuss the possible consequences of this action.

During a round at night, the nurse finds that a client is missing from his room. The client returns early next morning. What procedure is followed by the health care facility with regard to this client?

The client needs to repeat the admission procedure.

A client states that the client is "fed up" with the care that the client has been receiving in the hospital and plans to leave immediately. What procedure is followed with regard to this client?

The client needs to sign a form releasing the physician and agency from responsibility.

An elderly client fell 2 days ago on the sidewalk near home and has been admitted to the hospital with a hip fracture. Since the subsequent surgery, the client he has been insistent on wearing their own sweater and cap. The nurse is aware that the client is not cold, has no cognitive deficits, and has participated cooperatively in all aspects of his treatment. What is the most plausible rationale for the client's action?

The client wishes to maintain and assert their personal identity.

A nurse is aware that clear and accurate communication is necessary whenever clients are transferred or referred. Which situation best demonstrates a referral?

The nurse arranges for a client with a diabetic foot ulcer to see a podiatrist in community.

A nurse and an older adult client with chronic back pain are in the working phase of the nurse-client relationship. Which activity occurs in the working phase?

The nurse tries to avoid hampering the client's independence.

An 81-year-old resident of an intermediate care facility has been assessed and the nurse believes that a move to a skilled nursing facility may be justified. What aspect of the resident's health would warrant a move to a skilled nursing facility?

The resident has developed pressure ulcers on the backs of the heels.

A nursing student is conducting a client interview in order to determine the client's health history. The student's instructor observes that the student frequently twists her hair with her fingers while asking the client questions. What is the most plausible meaning of the student's nonverbal communication?

The student feels insecure during the interview

A nurse is working with an adult client who has been admitted with hyperglycemia following a period of poor glycemic control. The nurse has many similarities to the client with regard to age, gender, and socioeconomic status but is careful to utilize therapeutic communication techniques rather than social communication. How does therapeutic communication differ from social communication?

Therapeutic communication is focused on a particular goal while social communication is more superficial in content.

A client admitted to the health care facility for minor surgery is given a booklet by the nurse about the health care facility. Which of the following is a purpose of this booklet?

To orient the client to the facility

A nurse is caring for an older adult client. What strategy should the nurse include in order to facilitate effective communication?

Use active listening during communication.

The nurse is transferring a stroke client to a long-term care facility. The client lived at home prior to the illness, but now is aphasic and unable to provide independent care. Which action made by the nurse demonstrates appropriate completion of the client's medication reconciliation?

Verify current medications with the client's physician.

The nurse enters the room and the client is grimacing and guarding the abdomen. The client reports, "I have pain." What is the nurse's first priority?

assessing the client's level of pain

A nurse is asking a client health-related questions during a medical assessment. The client has developed lesions on the skin and warts around the mouth. Which factor affects oral communication?

attention and concentration

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mm Hg when all other vital signs are normal. This reflects what type of documentation?

charting by exception

When keeping a client's personal belongings in a locker, the nurse should ensure that the envelope is sealed and signed by which of the following people?

client, supervisor, and nurse

The client has been assessed by the emergency department physician and nurse. The physician wants the client to be observed overnight. The client refuses and wants to leave. What are the components of a properly executed against medical advice (AMA) discharge based on this scenario? (Select all that apply.)

consent properly documented all risks disclosed capacity to refuse

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

empathy

A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions made by the nurse will promote the development of a therapeutic relationship? (Select all that apply.)

encouraging the client to talk about the client's life, asking the client when the client would like to have the bed linens changed

The nurse is caring for the same client this week as last week, and the week before. Continuity of care is the process in which the client and the care team are involved in ongoing healthcare management. What is the function of continuity of care?

ensuring quality of care over time

A client admitted to the health care facility is assessed using a Minimum Data Set. How often is the Minimum Data Set repeated for a client?

every 3 month

A health care agency is applying for accreditation and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include:

evidence that nursing interventions have been evaluated in terms of the client's response.

7. A dlient has a diagnosis of stage 4 non-small cell lung cancer (NSCLC). The nurse consulted social services for discharge planning regarding appropriate level of care needed after chemotherapy. The client is able to provide partial self-care and will need pain medication. What setting is most appropriate for the client?

extended care

The nurse is caring for a client who is prescribed an antibiotic by mouth every 4 hours. When will the nurse document that the antibiotic has been given?

immediately following administration

A nurse has received change-of-shift report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." To improve the charting entry, it should:

include clearer descriptions of the client's mood and behavior.

The client is a disabled veteran with bilateral above the knee amputations (AKA). The client frequently has tender, erythemic areas along bilateral incision lines. Which type of facility will provide appropriate care for this client?

intermediate

The nurse is performing a comprehensive assessment of functional capability on a client that lives in a certified nursing home. What federally mandated process is the nurse completing?

minimum data set (MDS)

While covering a colleague's lunch break, a nurse on an orthopedic unit has responded to a client's call light. The client has requested assistance in transferring from the bed to the bathroom. The nurse has not previously provided care for this client and is unsure of the client's current activity orders. The client's current level of activity can be most easily verified by consulting what written source?

nursing kardex

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

A nurse is completing a health history on a client who has a hearing impairment. Which actions can the nurse take to enhance communication? (Select all that apply.)

providing paper and pencil for written communication assessing how the client would like to communicate

A physician is examining the client during the client's initial physical examination. After collecting all the data, the physician writes R/O in the medical records and suggests some more tests and examinations. What does the physician mean by R/O?

rule out

The client lives in a skilled nursing facility and has had an acute exacerbation of multiple sclerosis symptoms. What type of facility will provide the most appropriate care for this client?

skilled

A nurse is transferring a client with myocardial infarction (MI) to a tertiary care center. What referral information is most important for the nurse to relay to the receiving nurse so the client receives appropriate follow-up care?

summary of treatment started and current client condition

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

to investigate the quality of care in the agency