Nurs 224 Chapter 4 CoursePoint

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write a) "bilateral lung sounds clear." b) "the client's lung sounds were clear on both sides." c) "client's lung sounds were auscultated with stethoscope and were clear on both sides." d) "after listening to client's lung sounds, both lungs appeared clear."

a) "bilateral lung sounds clear."

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

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

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply): a) Accurate b) Organized c) Complete d) Biased e) Timely f) Concise

a) Accurate b) Organized c) Complete e) Timely f) Concise

A client is recovering from a total hip replacement. The plan of care for this client is based on previous standards and uses a multidisciplinary approach. The nurse is aware that this plan of care is also known as which of the following? a) Clinical pathway b) PIE system c) Database approach d) SOAPIE outline

a) Clinical pathway

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes? a) Evidence in a situation of wrongdoing. b) Evaluate nursing care provided. c) Discharge planning for the client. d) Reimbursement for care provided.

a) Evidence in a situation of wrongdoing.

A client is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with client teaching and medications to the client. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes: a) Identify necessary resources and strategies for successful home management. b) Make the chart look as complete and thorough as possible. c) Help ensure that the client feels more comfortable about returning home. d) Increase the nurse's level of competence.

a) Identify necessary resources and strategies for successful home management.

A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three clients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting? a) It contributes to many potential errors. b) It is a useful tool for prioritizing when busy. c) It helps you remember important information. d) It is fine unless you chart on the wrong client.

a) It contributes to many potential errors.

When performing an assessment, which of the following would be most helpful in validating a client's chief complaint? a) Objective data b) A genogram c) Past health history d) Family history data

a) Objective data

A client's pain has become increasingly severe, but the client has received the maximum doses of analgesics. The nurse is receiving a new analgesic order from the health care provider. How would the nurse best validate the new order? a) Read the order back to the health care provider for confirmation. b) Compare the order with the standard timing and dosage of the analgesic. c) Compare the order to the client's existing medication administration record (MAR). d) Have another nurse read the order that the nurse has transcribed.

a) Read the order back to the health care provider for confirmation.

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? a) Repeating the measurement with a different sphygmomanometer and stethoscope. b) Asking the physician to come in and take the client's blood pressure. c) Asking the client whether his diet has changed in the past year. d) Asking the client whether his exercise habits have changed recently.

a) Repeating the measurement with a different sphygmomanometer and stethoscope.

The nurse is reviewing a SOAPIE note in the client's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note. a) Subjective b) Objective c) Analysis d) Plan e) Evaluation

a) Subjective

After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following? a) Subjective data and objective data b) Interpretation and inference c) Observation and inspection d) Data and results

a) Subjective data and objective data

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

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

After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data? a) To communicate effectively with other health care team members. b) To provide protection from liability in the case of a lawsuit. c) To avoid penalties imposed by the federal government. d) To aid the nurse's recall of client information.

a) To communicate effectively with other health care team members.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations? a) When communicating a client's change in condition to the client's physician. b) When providing a change-of-shift report to a colleague. c) When documenting the care that was provided to a client whose condition recently deteriorated. d) When reporting to a client's family member or significant other.

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

A client asks to see his medical record (chart). How would the nurse respond? a) "I can't let you do that without a doctor's order." b) "I will get your chart and provide you with privacy to read it.'' c) "Our hospital policy is that you can't do that." d) "Why would you want to do that? It will only make you worry."

b) "I will get your chart and provide you with privacy to read it.''

A nurse has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow? Select all that apply. a) Verify every piece of data that was assessed. b) Decide whether the data require validation. c) Determine ways to validate the data. d) Repeat all objective assessments. e) Identify areas where data are missing.

b) Decide whether the data require validation. c) Determine ways to validate the data. e) Identify areas where data are missing.

A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data? a) Open-ended form b) Focused assessment form c) Frequent assessment form d) Ongoing assessment form

b) Focused assessment form

The nurse manager is implementing walking client rounds for the change-of-shift reports. One benefit of this type of reporting over others is: a) It is quicker b) It facilitates active participation of clients c) It frees up the report room d) It allows for exercise

b) It facilitates active participation of clients

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? a) Focus charting b) SOAP charting c) PIE charting d) Narrative charting

b) SOAP charting

The nursing instructor is teaching a class on documentation in the medical record. What would be the most important piece of information the instructor would give to the students? a) The focus system of documentation organizes entries by data, assessment, and response. b) The problem, intervention, evaluation (PIE) system of documentation does not use assessment as part of the PIE note. c) Narrative charting is the most reliable form of charting. d) Charting by exception (CBE) system allows the nurse to establish independent standards for assessment

b) The problem, intervention, evaluation (PIE) system of documentation does not use assessment as part of the PIE note.

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event? a) "Client visibly agitated during assessment and unwilling to continue." b) "Client became upset and terminated assessment." c) "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." d) "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

c) "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

Which of the following data entries follows the recommended guidelines for documenting data? a) "Patient is overwhelmed by the diagnosis of pancreatic cancer." b) "Patient kidneys are producing sufficient amount of measured urine." c) "Following oxygen administration, vital signs returned to baseline." d) "Patient complained about the quality of the nursing care provided on previous shift."

c) "Following oxygen administration, vital signs returned to baseline."

The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data? a) The client has a headache. b) The headache is upsetting the client. c) "I have pain across my entire forehead." d) The client doesn't want to bathe because of a headache.

c) "I have pain across my entire forehead."

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation? a) A blood pressure reading of 110/70 mm Hg in a competitive athlete. b) A pulse rate of 98 in a 10-year-old boy. c) A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight. d) A temperature of 97 degrees in an elderly woman.

c) A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight.

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call? a) Communicate face to face with good eye contact. b) Provide documentation of the data you are sharing. c) Ask the other nurse to read back what first nurse reported. d) Have the other nurse speak with the attending physician to clear up any misunderstandings.

c) Ask the other nurse to read back what first nurse reported.

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? a) Client has a dull, aching pain in the back of his head that began 2 weeks ago. The pain is constant and seems to be worse in the mornings. b) Client has severe headache, probably related to alcoholism. c) Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. d) Client reports headache.

c) Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained six (6) pounds over a week. How should the nurse validate if the weight taken is correct? a) Have the client weighed again on the same equipment. b) Verify if previously documented data was right. c) Compare if subjective findings support the data. d) Avoid questioning the client on the sudden weight gain.

c) Compare if subjective findings support the data.

What statement about batch charting is most accurate? a) It provides clear documentation. b) It makes the chart available to multiple users. c) It contributes to many potential errors. d) It facilitates completion in a timely manner.

c) It contributes to many potential errors.

What is the nurse's best defense if a client alleges nursing negligence? a) Testimony of other nurses b) Testimony of expert witnesses c) Patient's record d) Patient's family

c) Patient's record

What information concerning a client's respirations should the nurse record after completing a general physical assessment? a) Client's understanding of the assessment. b) Any existing chronic conditions that can affect respiration. c) Rate, rhythm, and depth of respirations taken for a full minute. d) Client's understanding of the factors that can affect respirations.

c) Rate, rhythm, and depth of respirations taken for a full minute.

Mistakes in charting can be costly to both the client and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following: a) Adverse reactions b) Side effects c) Sentinel events d) Mismanagement

c) Sentinel events

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? a) The laboratory assistant does not have the correct password. b) The laboratory assistant does not have the correct access number. c) The laboratory assistant can only retrieve medical records but cannot view the details. d) The laboratory assistant is trying to view archived data.

c) The laboratory assistant can only retrieve medical records but cannot view the details.

The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use? a) Written handoff b) Focus note c) Verbal handoff d) Patient Assessment Instrument

c) Verbal handoff

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? a) "Patient is guarding her abdomen and occasionally moaning." b) "Patient has a history of recent abdominal pain." c) "2 mg Dilaudid PO administration with good effect." d) "Patient complaining of abdominal pain rated 8/10."

d) "Patient complaining of abdominal pain rated 8/10."

The nurse assesses all assigned clients and sits in the nursing station to document assessment data for all clients. This is an example of: a) Point-of-care documentation b) Organized charting c) Accurate documentation d) Batch charting

d) Batch charting

If the nurse makes an error while documenting findings on a client's record, the nurse should a) Erase the error and make the correction. b) Obliterate the error and make the correction. c) Draw a line through the error and have it witnessed. d) Draw a line through the error, writing "error" and initialing.

d) Draw a line through the error, writing "error" and initialing.

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason? a) Health care institutions have established policies regarding documentation. b) Incorrect conclusions may be made without documentation of initial data. c) It satisfies legal standards established by health care organizations and institutions. d) It becomes the foundation for the entire nursing process.

d) It becomes the foundation for the entire nursing process.

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? a) Data base b) Problem list c) Plan of care d) Progress notes

d) Progress notes

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are a) Termed b) Progressive c) Specific d) Checklist e) Focused

e) Focused