Ch. 26 EAQ
A client is diagnosed with acute renal failure due to diabetes. Following treatment, the client recovers. The client is being discharged to home on insulin. The nurse is preparing a discharge summary for the client. What information should the nurse provide in the discharge summary? Select all that apply. 1 Entire biographical information of the client 2 Contact information of the health care provider 3 Step-by-step instructions for self-administration of insulin 4 Investigation procedures performed during the period of hospitalization 5 Signs and symptoms that have to be reported to the health care provider
2 Contact information of the health care provider 3 Step-by-step instructions for self-administration of insulin 5 Signs and symptoms that have to be reported to the health care provider A proper discharge planning is important to prepare clients for an effective and timely discharge from a health care institution. This is required for cost savings and ensuring reimbursement. Contact information of the health care providers is documented to help the clients contact them when needed. Step-by-step instructions about the procedures should be provided so that the client can refer to them while doing self-care procedures. Warning signs and symptoms that require the health care providers' attention should be documented in the discharge summary. Detailed biographical information of the client and all the investigations done during the period of hospitalization are not required to be documented in a discharge summary. Text Reference - p. 356
Which of the following charting entries is most accurate? 1 Client walked up and down hallway with assistance, tolerated well. 2 Client up, out of bed, walked down hallway and back to room, tolerated well. 3 Client up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied client during the walk. 4 Client walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise
Client walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. The answer that describes the client's actions and heart rate before and after exercise provides the most accurate, objective information for the chart . Text Reference - p. 350
A nurse caring for a client on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this client is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? 1 Electronic health record 2 Clinical documentation 3 Clinical decision support system 4 Computerized physician order entry
Clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user. Text Reference - p. 360
Using the SOAP format, which represents the appropriate "P" statement? 1 Reposition the client on right side. Encourage client to use patient-controlled analgesia (PCA) device. 2 The client states, "The pain increases every time I try to turn on my left side." 3 Acute pain is related to tissue injury from surgical incision. 4 Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.
Reposition the client on right side. Encourage client to use patient-controlled analgesia (PCA) device. The planning statement is, "Reposition the client on right side. Encourage client to use patient-controlled analgesia (PCA) device." The subjective statement is the client's statement: "The pain increases every time I try to turn on my left side." The objective statement is, "Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation." The assessment statement is, "Acute pain is related to tissue injury from surgical incision." STUDY TIP: Be sure to have the meanings of each letter of SOAP memorized and understand what types of information go into each section. Text Reference - p. 354
As you enter the client's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the client's emotional status? 1 The client has a defiant attitude and is demanding his test results. 2 The client appears to be upset with his nurse because he wants his test results immediately. 3 The client is demanding and complains frequently about his doctor. 4 The client stated that he felt frustrated by the lack of information he received regarding his tests.
The client stated that he felt frustrated by the lack of information he received regarding his tests. "The client stated that he felt frustrated by the lack of information he received regarding his tests" is a nonjudgmental statement regarding the nurse's observations about the client. Statements about the client being "defiant" or "demanding" are judgmental, and information in the medical record should be factual and nonjudgmental. The statement about the client appearing to be "upset" needs to be more specific regarding the reason for the client's concern. Text Reference - p. 350
