PrepU Funds. Assignment 2 Ch.5

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

Which data entry follows the recommended guidelines for documenting data?

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

Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area.

"I have a fair amount of pain in my belly near my incision"

The parents of a client ask the nurse to review the medical 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."

The unlicensed assistive personnel (UAP) has taken vital signs. The nurse is currently logged into the electronic health record, and the UAP needs to document the vital signs. How does the nurse the UAP to document?

"I will log out of the electronic health record and you can log in to document."

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 student nurse is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

Which nursing assessments should the nurse take into consideration before making entry into clients' record? (Select all that apply.)

-reviewing the agency's list of approved abbreviations -locating the clients' files within an electronic recording system -identifying the paper form appropriate to be used for documenting

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.

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

A flow sheet

Which are examples of breaches of client confidentiality? Select all that apply.

A nurse discusses a client with a coworker in the elevator. A nurse shares her computer password with a relative of a client. A nurse updates the employer of a client regarding the client's return to work

A client with hemiplegia has been admitted to the health agency. The nurse who cares for the client has a fixed routine of cleaning, feeding, and administering medicines to the client. Which of the following should the nurse use to record these details?

Checklists

Which are principles of documentation? Select all that apply.

Confidentiality Accuracy Objective Timely

Which of the following is not a purpose of the medical record?

Contract

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

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? (Select all that apply.)

Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas. Conversations about clients must take place in private places where they cannot be overheard.

A nurse is preparing an educational session on the purpose of documentation in medical records. Which topics should the nurse include in the education session? Select all that apply.

Facilitates quality Serves as a financial record Supports decision analysis Assists with clinical research

Which statement is not true regarding a medication administration record (MAR)?

If the client refuses the dose you don't have to document this on the MAR.

A health care agency has been asked to compensate a client as per a lawsuit filed for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which situation is a HIPAA violation?

Not informing a client in writing of the purpose of sharing his or her personal details

Which principle should guide the nurse's documentation of entries on the client's medical record?

Precise measurements should be used rather than approximations.

Which method of documentation is organized around client diagnoses rather than around client information?

Problem-oriented medical record (POMR)

In order to improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?

Recommendations

Charting in which the nurse writes a progress note that relates to one health problem is a:

SOAP note

In what type of documentation does a nurse record narrative notes in a nursing section?

Source-oriented record

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.

A client has requested a translator so that she can understand the questions that the nurse is asking her during the client interview. The nurse knows what is important when working with a client translator?

That translators may need additional explanations of medical terms

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

The nurse documents clients' responses to nursing interventions.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data, as per the Health Insurance Portability and Accountability Act at health agencies?

The nurse locks out client information, except to those who have been authorized through fingerprints or voice activation

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

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

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 interviewing a newly admitted client. Quoting statements made by the client will help in maintaining:

objectivity.

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

omitting client's response to nursing interventions

When taking a telephone order from a physician, the nurse verifies that she understands the order by:

repeating the order back to the physician.

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

urine output 100 ml