Fundamentals Chapter 19

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? A. "I will arrange access for you to review the record after you put your request in writing." B. "Only the client has the right to review the health care records." C. "No, the physician will not give you access to review the records." D. "Are you questioning the care of your child?"

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

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

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

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? A. Create an addendum with a correction. B. Immediately delete the incorrect documentation. C. Contact the health care provider. D. Contact information technology (IT) staff to make the correction.

A. Create an addendum with a correction.

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

A. It provides quick access to abnormal findings.

Which abbreviation is correct for use in documentation? A. PO B. BT C. Per os D. Sub q

A. PO

Which are appropriate actions for protecting clients' identities? Select all that apply. A. Place light boxes for examining X-rays with the client's name in private areas. B. Have conversations about clients in private places where they cannot be overheard. C. Document all personnel who have accessed a client's record. D. Ensure that clients' names on charts are visible to the public. E. Orient computer screens toward the public view.

A. Place light boxes for examining X-rays with the client's name in private areas. B. Have conversations about clients in private places where they cannot be overheard. C. Document all personnel who have accessed a client's record.

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? A. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. B. Problem-oriented recording gives clients the right to withhold the release of their information to anyone. C. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. D. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care.

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

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply. A. Showing the provider the trends from baseline to present in blood pressure B. Informing the provider of the client's present heart rate of 116 beats/min C. Writing the hemoccult result on a piece of paper and leaving it at the desk D. Placing a note on the computer terminal with the client's name and information E. Faxing the results of blood chemistry levels to the provider's office

A. Showing the provider the trends from baseline to present in blood pressure B. Informing the provider of the client's present heart rate of 116 beats/min E. Faxing the results of blood chemistry levels to the provider's office

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? A. The client reports that on a scale of 0 to 10, the current pain is a 3. B. The client is receiving sufficient relief from pain medication, stating no pain in either knee. C. The client appears to have a low tolerance for pain and frequently reports intense pain. D. The client appears comfortable and is resting adequately and appears to not be in acute distress.

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

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. a referral. B. a consultation. C. conferring. D. reporting.

A. a referral.

The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse? A. "You may not understand all of the information and it will confuse you so I will help you decipher it all." B. "I will have to review the policy that determines what procedure is in place for client access." C. "Let me open up the computer access so that you can see what information is of interest to you." D. "The hospital owns your records and does not have to allow you access while you are a client here."

B. "I will have to review the policy that determines what procedure is in place for client access."

The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? A. "The benefit of CBE is that it demonstrates whether high-quality care is given." B. "The benefit of CBE is less time needed on computer charting." C. "CBE is a relatively new format of documentation in electronic health records." D. "CBE is the best way to protect against lawsuits."

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

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? A. Take the parent to the client's room and have the client give the requested information. B. Ask the client if information can be given to the parent. C. Explain the reasons for the hospitalization, but give no further information. D. Provide the information to the parent.

B. Ask the client if information can be given to the parent.

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? A. Notify the client relations department about the breach of privacy. B. Remind the UAP about the client's right to privacy. C. Report the UAP to the nurse manager. D. Document the UAP's conversation.

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

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

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

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

B. a client who is homebound and needs skilled nursing care

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

B. have the right to copy their health records.

The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation? A. inform the client's family that the client is being neglected at home B. immediately report the suspected abuse of the client. C. avoid reporting the abuse as it would be a privacy and confidentiality violation D. discuss the abuse with coworkers to determine what should be done

B. immediately report the suspected abuse of the client.

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

B. 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: A. using only those abbreviations that are defined in full at another location in the client's chart. B. limiting abbreviations to those approved for use by the institution. C. using only abbreviations whose meaning is self-evident to an educated health professional. D. ensuring that abbreviations are understandable to clients who may seek access to their health records.

B. limiting abbreviations to those approved for use by the institution.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? A. pain rating of 4 on a scale of 0-10 B. urine output 100 ml C. concerned with feeling tired D. describes wound as itchy

B. urine output 100 ml

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? A. "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." B. "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin." C. "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." D. "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."

C. "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."

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? A. 1 bottle of glucose B. One U of glucose C. 1 Unit of glucose D. 1U of glucose

C. 1 Unit of glucose

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? A. following up the incident with other members of the care team B. gauging the nurse's professional performance over time C. identifying risks and ensuring future safety for clients D. protecting the nurse and the hospital from litigation

C. identifying risks and ensuring future safety for clients

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? A. "It will give me a better sense of what my workload will be today." B. "It makes our client feel like we care, especially if we start the day off with a clean room." C. "It will let me see everything that has been done and things that need to be done." D. "It will allow for us to see the client and possibly increase client participation in care."

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

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. B. A client who resides in Indiana has required hospitalization during a vacation in Hawaii. C. A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. D. A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

D. A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? A. Accreditation B. Psychomotor skills C. Clinical judgment D. Documentation

D. Documentation

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 +"? A. PIE B. Narrative C. Exception D. FOCUS

D. FOCUS

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? A. Add the new order to the medication administration record. B. Write the order in the client's record. C. Call the pharmacy to have the order entered in the electronic record. D. Inform the health care provider that a written order is needed.

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

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? A. Discuss how the hospital can be fined for allowing clients to view their health care records. B. Access the health care record at the bedside and show the client how to navigate the electronic health record. C. Explain that only a paper copy of the health care record can be viewed by the client. D. Review the hospital's process for allowing clients to view their health care records.

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

Which organization audits charts regularly? A. Sigma Theta Tau International B. American Nurses Association C. National League for Nursing D. The Joint Commission

D. The Joint Commission

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? A. The client is coughing and experiencing severe heartburn in the morning. B. The client has a history of severe complaints in the morning. C. The client has symptoms in the morning associated with a heart attack. D. The client reports waking up this morning with a severe headache.

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

Which finding from a nursing audit reflects high standards for client safety and institutional health care? A. The nurse fails to adequately complete data on clients' health histories and discharge planning. B. The nurse fails to identify the nursing diagnoses or clients' needs. C. The nurse records inappropriate nursing interventions. D. The nurse documents clients' responses to nursing interventions.

D. The nurse documents clients' responses to nursing interventions.

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? A. plan of care B. data base C. problem list D. progress notes

D. progress notes

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states: A. The use of rationales is not commonly practiced in the clinical setting. B. The rationale is deleted to provide additional charting space in the computer system. C. Some facilities do not require them on their plans of care. D. Rationales are only important while the nurse is in training. E. Although not written, the nurse must know or question the rationale before performing an action.

E. Although not written, the nurse must know or question the rationale before performing an action.