Funds Ch 16

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for patients diagnosed with multiple sclerosis, and their families. Providing this information is an example of which of the following?

A referral

Besides using the medical records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift?

Change of shift reports

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

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is what?

Retrieval of information is more efficient

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

1 unit of glucose

Which of the following clinical situations 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 physician wrote in his chart.

A hospital is charting 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 nurse document the significant finding 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

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 the clients status. Which documentation method would the group most likely suggest?

Charting by exception

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal hand-off report?

Current client assessment

A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of the following would the nurse expect to include when preparing the verbal handoff report?

Current client assessment

When maintaing 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

The student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it is on the "do not use" list of the join commission on accreditation of healthcare organizations (JCAHO)?

Epogen 6500 U SQ daily (U is not approved for unit)

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 her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

Identifying risks and ensuring future safety for clients

A physician suggests that the nurse use the computer terminal that is available at the pint of care or at the client's bedside. What is the probable reason for the physician's suggestion?

It keeps the nurse close to the source of the data.

A group of nurses has established a focus group and pilot study to examine the potential application data assistants (PDAs) in bedside care. This study is a tangible application of what?

Nursing informatics

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 the nurse involved in the client's car are required to collate all of the information for easy access. Which style do you think the agency is following in order to record the client's 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 of care of the client. Which of the following styles of documentation is the nursing implementing?

SOAP charting

Which of the following information about the patient would a nurse include as part of a minimum data set when using electronic medical records?

Sex, insurance, and admission date

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

Sign each entry by name and title

How can the nurse researcher obtain information from a client record?

Study clients records

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.

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 he nurse refuses. THe nurse's refusal is based on the understanding that which of the following people would be entitles to access of the client's records?

Those directly involved in the client's care.

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

A new graduate is working at her first job. Which of the following statements is most important for the new nurse to follow.

Use abbreviations approved by the facility

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations?

When communicating a client's change in condition to the client's physician.

When taking a telephone order from a physician, the nurse verifies that he or she understands the order by...

repeating the order back to the physician