Fundamentals - Chapter 19

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? "Any information that can identify a person is considered a breach of client privacy." "You may continue to post about a client, as long as you do not use the client's name." "All aspects of clinical practice are confidential and should not be discussed." "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."

"Any information that can identify a person is considered a breach of client privacy."

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 am calling because the client receiving blood has developed dyspnea and had crackles." "This client has a medical history of heart failure." "It seems like this client has fluid volume overload." "I think the client would benefit from intravenous furosemide."

"I think the client would benefit from intravenous furosemide."

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 provide data for legal evidence." "I can share the clients' medical records with the health care team." "The clients' medical records are an obstruction to research and education." "The clients' health records should be used to promote reimbursement from insurance companies"

"The clients' medical records are an obstruction to research and education."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR? "I am concerned that the client might be exhibiting sepsis." "The client's temperature has been 102°F (38.9°C) for the last 6 hours." "The client was admitted today with a urinary tract infection." "Will you prescribe a complete blood count to check the white blood cell count and a culture?"

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

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 1 bottle of glucose One U of glucose 1U of glucose

1 Unit of glucose

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use? 0815 0945 1945 2015

2015

Which pieces of information should the nurse treat as confidential and not disclose? Select all that apply. A client's diagnosis linked to a disease outbreak A client's Social Security number Information about a client's past health conditions A client's address A deceased client's history for organ donation

A client's Social Security number Information about a client's past health conditions A client's address

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? Incident report Nurse's shift report Transfer report Telemedicine report

Incident report

Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing? Nutritional consult Social services consult Pulmonologist referral Podiatry referral

Nutritional consult

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take? Review the nursing care plan. Implement changes in the current interventions. Involve the family in changes. Revise the plan of care.

Revise the plan of care.

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? FOCUS charting SOAP charting PIE charting narrative charting

SOAP charting

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his or her charting? Select all that apply. The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today." The client seems depressed. The client is suicidal. The client is in a bad mood.

The client is crying. The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."

A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? The lower extremities Lung sounds Heart rate and rhythm The abdominal area

The lower extremities

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can accept verbal orders to provide immediate care and record once the client is stable. The provider can input orders remotely into the EHR system for the nurse to retrieve. The nurse can implement care once written orders are received from the provider. The client must be stabilized before the nurse can obtain any orders from the provider.

The nurse can accept verbal orders to provide immediate care and record once the client is stable.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it. Translators may need additional explanations of medical terms.

Translators may need additional explanations of medical terms.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: have the right to copy their health records. need to obtain legal representation to update their health records. can be punished for violating guidelines. are required to obtain health record information through their insurance company.

have the right to copy their health records.

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? data base problem list plan of care progress notes

progress notes

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

subjectivity

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." "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

"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."

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting? "If I make an error, I can draw a red circle around it." "If I make an error, I have to rewrite the entire entry." "If I make an error, I draw a single line through it and put my initials by it." "If I make an error, I use white-out on it."

"If I make an error, I draw a single line through it and put my initials by it."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will allow for us to see the client and possibly increase client participation in care." "It will let me see everything that has been done and things that need to be done." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will give me a better sense of what my workload will be today."

"It will allow for us to see the client and possibly increase client participation in care."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? "Let me get that for you." "Only authorized persons are allowed to access client records." "The provider will need to give permission for you to review." "I am sorry I can't access that information."

"Only authorized persons are allowed to access client records."

A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift? "No medical issues overnight that require immediate attention." "The unlicensed assistive personnel turned the client every 2 hours last night, but the client should continue to be repositioned during the day." "The client had a good deal of anxiety last night and requested to be turned and repositioned frequently." "The client was very restless last night so you may need to call the health care provider today to get a prescription for the client's anxiety."

"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."

A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? "You can fill in information from your own records and store it on your computer or the Internet." "You can link your record to a specific health care organization's electronic health record system." "Your health care provider is obligated to read your personal health record and share it with your insurance provider." "Your entire health care team may access and securely share your vital medical information electronically."

"You can fill in information from your own records and store it on your computer or the Internet."

A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? Fill out an incident report. Attach a copy of the incident report to the chart. Stop the infusion and document the time. Report the error to the primary provider.

Attach a copy of the incident report to the chart.

Which note includes all elements of a SOAP note? 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. Client reports nausea, vomiting, and diarrhea × 3 days. Denies any sick contacts or recent travel. Mucous membranes moist, blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Client reports nausea and vomiting × 3 days. Vital signs stable. Most likely due to gastroenteritis. Client with nausea, vomiting, diarrhea, most likely secondary to gastroenteritis. Will give an antiemetic and reassess.

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.

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information? Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." Client states expecting some pain, but it is more severe than anticipated. Abdomen soft, slightly tender on palpation. Incision clean, dry and intact. Positive bowel sounds all four quadrants. Client is requesting pain medications, is grimacing, and is diaphoretic.

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents? Client's record and occurrence report Occurrence report and critical pathway Critical pathway and care plan Care plan and client's record

Client's record and occurrence report

Which is the primary purpose of client records? Communication Reimbursement Legal protection Performance improvement

Communication

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error? Immediately delete the incorrect documentation. Create an addendum with a correction. Contact information technology (IT) staff to make the correction. Contact the health care provider.

Create an addendum with a correction.

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 +"? PIE FOCUS Narrative Exception

FOCUS

Which statement is not true regarding a medication administration record (MAR)? If the client declines the dose, the nurse does not have to document this on the MAR. The MAR distinguishes between routine and "as needed" medications. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.

If the client declines the dose, the nurse does not have to document this on the MAR.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? Inform the health care provider that a written order is needed. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record.

Inform the health care provider that a written order is needed.

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse? Proceed with the order since the nurse heard it the first time Don't follow through with the order, and delete it from the record Inform the provider, to ensure safety for the client, it must be read back Ask the secretary to call the provider back and take the order

Inform the provider, to ensure safety for the client, it must be read back

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 documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.

It provides quick access to abnormal findings.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Making the names of clients on charts visible to the public

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Recording nursing interventions Identifying nursing diagnoses or clients' needs Omitting clients' responses to nursing interventions Documenting clients' health histories and discharge planning

Omitting clients' responses to nursing interventions

Which principle should guide the nurse's documentation of entries on the client's health care record? Correcting fluid is used rather than erasing errors. Documentation does not include photographs. Precise measurements should be used rather than approximations. Nurses should not refer to the names of physicians.

Precise measurements should be used rather than approximations.

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method? Source-oriented method PIE charting method Problem-oriented method Focus charting method

Problem-oriented method

The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply. Read back the prescription. Record the date and time of the prescription. Include V.O. with the health care provider's name on the prescription. Have the health care provider review and sign the prescription during the emergency. Record the prescription on the pharmacy discrepancy sheet.

Read back the prescription. Record the date and time of the prescription. Include V.O. with the health care provider's name on the prescription.

In SBAR, what does R stand for? Reinforcing data Response Recommendations Report

Recommendations

When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings? Call the health department. Clean up the house. Move the client to an assisted living facility. Refer to the health care provider.

Refer to the health care provider.

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? Remind the UAP about the client's right to privacy. Report the UAP to the nurse manager. Notify the client relations department about the breach of privacy. Document the UAP's conversation.

Remind the UAP about the client's right to privacy.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? Dialogue Documentation Reporting Verification

Reporting

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? Review the hospital's process for allowing clients to view their health care records. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.

Review the hospital's process for allowing clients to view their health care records.

A nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process? Select all that apply. S: The nurse handling the transfer describes the client situation to the new nurse. S: The nurse discusses the client's symptoms with the new nurse in charge. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse explains the rules of the new facility to the client. R: The nurse gives recommendations for future care to the new nurse in charge.

S: The nurse handling the transfer describes the client situation to the new nurse. B: The nurse gives the background of the client by explaining the client history. A: The nurse presents an assessment of the client to the new nurse. R: The nurse gives recommendations for future care to the new nurse in charge.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Disclosing client health information for research purposes after obtaining permission from the client's physician Releasing the client's entire health record when only portions of the information are needed Submitting a written notice to all clients identifying the uses and disclosures of their health information Obtaining only the client's verbal acknowledgement of having been informed of the disclosure of information

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

The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? The client is receiving sufficient relief from pain medication, stating no pain in either knee. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client reports that on a scale of 0 to 10, the current pain is a 3. The client appears to have a low tolerance for pain and frequently reports intense pain.

The client reports that on a scale of 0 to 10, the current pain is a 3.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client reports waking up this morning with a severe headache. The client has symptoms in the morning associated with a heart attack. The client is coughing and experiencing severe heartburn in the morning. The client has a history of severe complaints in the morning.

The client reports waking up this morning with a severe headache.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. The nurse sends or directs someone to take action in a specific nursing care problem.

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

Which example may illustrate a breach of confidentiality and security of client information? The nurse provides information over the phone to the client's family member who lives in a neighboring state. The nurse provides information to a professional caregiver involved in the care of the client. The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell.

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information? The physician's assessment and treatment Results of laboratory and diagnostic studies Nursing documentation and plan of care Information from other members of the health care team

The physician's assessment and treatment

Which is not a purpose of the client care record? To serve as a legal document To facilitate reimbursement To serve as a contract with the client To assist with care planning

To serve as a contract with the client

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? Do not release any information to the insurance company. Use minimum disclosure policy to release the information. Refer the insurance agency directly to the client. Release the full medical record to expedite payment.

Use minimum disclosure policy to release the information.

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate? Write a narrative note in the designated nursing section. Place the narrative note chronologically after the respiratory therapist's note. Review the laboratory results under the physician section. Use a critical pathway to document the physical assessment.

Write a narrative note in the designated nursing section.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client who is homebound and needs skilled nursing care a client whose rehabilitation potential is not good a client whose status is stabilized a client who is not making progress in expected outcomes of care

a client who is homebound and needs skilled nursing care

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. what the client watched on television during the shift what time the nurse will return for the next shift any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

A nurse is part of a team that will be working in a new orthopedic unit to determine the most appropriate method for documentation. The team agrees to initiate the practice of an abbreviated form of documentation that requires less nursing time and readily detects changes in client status. Which documentation method would the group most likely suggest? charting by exception narrative notes problem, intervention, and evaluation note FOCUS data, action, and response note

charting by exception

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. interpretation of data. important information. relevant data.

interpretation of data.

When documenting the care of a client, 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. using only abbreviations whose meaning is self-evident to an educated health professional . ensuring that abbreviations are understandable to clients who may seek access to their health records. using only those abbreviations that are defined in full at another location in the client's chart.

limiting abbreviations to those approved for use by the institution.

What dual purpose does an audit serve? communication and evaluation knowledge and quality education and confidentiality quality assurance and reimbursement

quality assurance and reimbursement

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis? the client's family the public health department Health Canada the client's employer

the public health department

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? those directly involved in the client's care any family member of the client close friends of the client health care professionals of the facility

those directly involved in the client's care