Chapter 9 : Prep U

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?

"Client is reporting abdominal pain is rated at 8/10."

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

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

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

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

The nurse is on a committee at an agency that has the task of identifying a need related to a new electronic health record (EHR) and providing supporting baseline data. In the System Development Lifecycle, what is this phase called?

analyze & plan

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 parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing."

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"It combines nursing science w/ information management & analytical sciences

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."

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate?

"The benefit of CBE is less time needed on computer charting."

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 & education."

The nurse is caring for a client who states, "I do not feel very well right now. It is very cold in here." The client's temperature is 103.1°F (39.5°C). The client's heart rate is 103 beats/min. The nurse responds to this finding by administering acetaminophen and encouraging the client to drink more fluids. Using the SOAP method of charting, what will the nurse document in the client record?

- Client reports, "I do not feel well. It is very cold in here." - Client is febrile - temperature is 103.1 F (39.5C) - Heart rate is 103 beats/min - Acetaminophen 650 mg PO PRN given - Encouraged client to increase fluid intake

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

0000

In the computer, the nurse needs to document the time the client took medication. However, the time is written in the military format, and the computer accepts only the traditional format. How should the nurse enter the time in the computer if the client took his medication at 1530 hours?

03:30 pm

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

A nurse has administered six units of insulin to the client as per order. What is the safest documentation of this information?

6 units of insulin administered

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his health care provider wrote in his chart

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 practice should the nurse adopt when communicating and documenting electronically?

Include precise measurements in documentation rather than approximations

During rounds, the nurse finds that a client with paralysis has fallen from the bed because the unlicensed assistive personnel (UAP) failed to raise the side rails after giving the client a bath. The nurse assists the client back to bed and performs an assessment of the client for injury. As per the agency policies, the nurse fills out an incident report. What would be most appropriate for the nurse to do?

Include time & date of the incident on the form

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers

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

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.

SOAP

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Submitting a written notice to all clients identifying the uses & disclosures of their health information

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to?

The Joint Commission

The nurse is caring for a client on a medical unit that uses focused charting to document client care. Which written statement by the nurse demonstrates the use of focused charting to document the client assessment?

The client rates abdominal pain at 8/10.

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 w/ a severe headache

The health records department of a hospital has received a request from an insurance provider for a client's health records. The request has been authorized by the client and bears the client's signature. What principle should guide the hospital's release of the client's records?

The hospital should release the minimum amount of data that is necessary for the purposes of the request

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?

The laboratory assistant can only retrieve client records but cannot view the details

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurses documents clients' responses to nursing interventions

Which method of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

charting by exception

A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

charting by exception (CBE)

What ensures continuity of care?

communication

The nurse documents a progress note in the wrong client's electronic health record (EHR). Which action would the nurse take once realizing the error?

create a notation w/ a correction

An informatics nurse specialist is describing the role of informatics in health care to a group of staff at a facility. The nurse specialist determines that the teaching was successful when the group identifies which as a core practice area?

electronic health record

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

narrative notes

A nurse at a community-health center is completing an audit of client records. The outcomes of this project will serve what set of purposes?

quality assurance & reimbursement

An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should:

recommend 40 mg of furosemide be administered because the client had improvement with past administration

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the health care provider's information in the health care provider's progress notes. The nurse is using which method of documentation?

source-oriented

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

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity

A nurse has responded to a client's call light, and the client has asked for assistance in transferring from the bed to the bathroom. However, the nurse has not previously been involved in the client's care and does not know the client's current activity orders. Where could the nurse most easily access this information?

the nursing Kardex

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

urine output 100 ml

A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy?

use minimum disclosure policy to release the information

A nurse is documenting care in a source-oriented record. What action by the nurse is mostappropriate?

write a narrative note in the designated nursing section

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan