Ch. 15

The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes

Correct Answer: 2 Rationale 1: The problem statement is labeled "P" and referred to by number. Rationale 2: The interventions employed to manage the problem are labeled "I" and numbered according to the problem. Rationale 3: The "E" is the evaluation of the effectiveness of the intervention and is labeled and numbered according to the problem. Rationale 4: Progress notes are not part of the identified labels of PIE charting.

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

Correct Answer: 3 Rationale 1: The database consists of all known information about the client upon admission. Rationale 2: The problem list includes all identified problems, listed in the order in which they are identified. Rationale 3: The initial list of orders or plan of care is made with reference to the client's active problems in this type of charting. Physicians write physician orders or the medical care plan. Rationale 4: Progress notes are chart entries made by all health professionals involved in the client's care.

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The client's record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake.

Correct Answer: 1 Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The client's clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Coded diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses. Rationale 2: This would not necessarily result in the problem related to reimbursement because it is a reasonable diagnostic test to perform in this situation. Rationale 3: This would not necessarily result in the problem related to reimbursement. Rationale 4: This would not necessarily result in the problem related to reimbursement.

The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM

Correct Answer: 1 Rationale 1: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layperson's terms, and use of medical abbreviations should be avoided. "Twice a day" should be written out, not abbreviated as "bid." Rationale 2: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layperson's terms, and use of medical abbreviations should be avoided. "Twice a day" should be written out, not abbreviated as "bid." Rationale 3: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layperson's terms, and use of medical abbreviations should be avoided. "Twice a day" should be written out, not abbreviated as "bid." Rationale 4: If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layperson's terms, and use of medical abbreviations should be avoided. "Twice a day" should be written out, not abbreviated as "bid."

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans 2. Traditional care plans 3. Critical pathways 4. Kardex

Correct Answer: 1 Rationale 1: Standardized care plans were developed to save documentation time. These plans may be based on an institution's standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans are usually individualized to address each client's specific needs. Rationale 2: Traditional care plans are written for each client, are specific, and are individualized for that client. Rationale 3: Critical pathways are used in case management, involving a multidisciplinary approach to planning and documenting client care. Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible for all health professionals.

The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning

Correct Answer: 1 Rationale 1: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client's words; otherwise, they are summarized. Rationale 2: Objective data consist of information that is measured or observed. Rationale 3: Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the client's condition and level of progress are subsequently described. Rationale 4: Planning is the care designed to resolve the problem.

A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex

Correct Answer: 1 Rationale 1: The Minimum Data Set (MDS) for assessment and care screening must be performed within 4 days of a client's admission to a long-term care facility and reviewed every 3 months. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. Rationale 2: Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. Rationale 3: CBE stands for charting by exception and is not the form of documentation used for this type of assessment. Rationale 4: Kardex is a system of organizing client information so it can be accessed quickly. It is usually used in the acute care area.

When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the client's chart. Which type of documentation system is the nurse using? 1. Source-oriented record 2. Problem-oriented record 3. Case management 4. Focus charting

Correct Answer: 1 Rationale 1: The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the client's chart. Rationale 2: In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information. Rationale 3: Case management uses a multidisciplinary approach to documenting client care, called critical pathways. Rationale 4: Focus charting is intended to make the client and client concerns the focus of care, utilizing a three-column format.

The nurse is using I-SBAR to provide a report to an intensive care nurse for a client transfer. Which statements indicate that the nurse is using this communication technique appropriately? Standard Text: Select all that apply. 1. "Mr. Collins has a history of peptic ulcer disease." 2. "Hi Susan, my name is Janie and I've been taking care of Mr. Collins all day." 3. "It's no wonder he's bleeding from his stomach; he drinks a six pack of beer every day." 4. "Late this morning Mr. Collins became nauseated and vomited 250 mL of bright red emesis." 5. "He has bowel sounds in all 4 quadrants, is not experiencing any pain, but has a heart rate of 110 and blood pressure of 98/50 mm Hg."

Correct Answer: 1, 2, 4, 5 Rationale 1: This statement provides background information. Rationale 2: This statement serves as an introduction Rationale 3: This statement is an opinion and has no place when using I-SBAR communication. Rationale 4: This statement provides the situation. Rationale 5: This statement provides the assessment.

The nurse is documenting care provided to a client. Which action should the nurse take to demonstrate the avoidance of potentially confusing abbreviations when documenting? Standard Text: Select all that apply. 1. Documenting vital signs as "TPR." 2. Charting that the "drsg was dry and intact." 3. Transcribing a verbal order as "Carbamazepine 12 mcg/ml IV push daily." 4. Documenting "Client consistently requesting IM MS for pain well before prescribed time." 5. Charting, "Client to be ambulated q.i.d."

Correct Answer: 1, 2, 5 Rationale 1: This is a commonly used and accepted abbreviation for temperature, pulse, and respirations (vital signs). Rationale 2: This is a commonly used and accepted abbreviation for a treatment dressing. Rationale 3: Mcg (micrograms) is not an accepted abbreviation, as it can be confused with mg (milligrams), resulting in a one thousand-fold overdose. Rationale 4: MS is not an accepted abbreviation for morphine sulfate, as it can be confused with magnesium sulfate, resulting in a drug error. Rationale 5: This is a commonly used and accepted abbreviation for four times a day.

The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? SATA 1. A firewall to protect the server from unauthorized access 2. One unit password to protect the unit's information 3. Expectation to log off a terminal after using it 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets

Correct Answer: 1, 3, 5 Rationale 1: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include the installation of a firewall to protect from unauthorized access. Rationale 2: Guidelines for confidentiality and security of computerized records include assignment of a personal password to enter and log off computer files. The password should not be shared with anyone, including other team members. Rationale 3: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. The nurse should learn to never leaving a monitor unattended after logging on. Rationale 4: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Turning the monitor away from view is not a sufficient safeguard. Rationale 5: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include shredding all confidential information.

The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care. Which actions should the nurse take to prove adherence? Standard Text: Select all that apply. 1. Charting the client's response to pain medication taken 2. Describing the client as "appearing to be comfortable" 3. Leaving sufficient charting space for the previous shift to chart client teaching 4. Documenting that the client reports, "I'm so afraid of tomorrow's surgery" 5. Making a late entry regarding a client's request for pain medication

Correct Answer: 1, 4, 5 Rationale 1: Documentation guidelines include charting a change in a client's condition and showing that follow-up actions were taken. Rationale 2: Documentation guidelines include not using vague terms (e.g., "appears to be comfortable"). Rationale 3: Documentation guidelines include not leaving a blank space for a colleague to chart later. Rationale 4: Documentation guidelines include recording the client's actual words by putting quotation marks around the words. Rationale 5: Documentation guidelines include the idea that a late entry is better than no entry.

A client's condition has deteriorated and the nurse needs to notify the health care provider. What information should the nurse include when providing a telephone report on this client? Standard Text: Select all that apply. 1. Client's medical diagnosis 2. Name of unit nurse manager 3. Names of family members visiting 4. Name and relationship to the client 5. Observed changes in the client's status

Correct Answer: 1, 4, 5 Rationale 1: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. Telephone reports usually include the client's medical diagnosis. Rationale 2: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. The name of the unit nurse manager is not information provided during a telephone report. Rationale 3: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. The names of visitors are not information provided during a telephone report. Rationale 4: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. The nurse should begin with his or her name and relationship to the client. Rationale 5: When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. A telephone report usually includes changes in nursing assessment, vital signs related to baseline vital signs, and significant laboratory data.

A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation

Correct Answer: 2 Rationale 1: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an unattainable goal because a change in the client's care plan may result in success. Rationale 2: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is called a variance. Variances are deviations to what is planned in the critical pathway—unexpected occurrences that affect the planned care or the client's response to care. Rationale 3: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an error in care planning because the success of a goal is dependent on specific interventions and individual client response. Rationale 4: Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is not referred to as an error in implementation because the success of a goal is not solely dependent on the implementation of a single intervention.

A client has specific cultural needs that affect the plan of care. In which part of the client's problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes

Correct Answer: 2 Rationale 1: The database includes information about the client when admitted to the facility. Rationale 2: The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs. Rationale 3: The plan of care is made with reference to the active problems. Rationale 4: Progress notes are chart entries made by all health professionals involved in a client's care.

A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as it's his record. How should the nurse respond to this client's request? 1. "You'll have to ask your doctor for permission to do that." 2. "Actually, the original record is the property of the hospital, but you are welcome to copies of your records." 3. "We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details." 4. "There's a new law that protects your records, so you're not going to be able to have access to them."

Correct Answer: 2 Rationale 1: The doctor's permission is not a requirement for the release of a client's medical record. Rationale 2: Although the client's record is protected legally as private, access to the record is restricted to health professionals involved in the client's care. The institution or agency is the rightful owner of the client's record, but the client has the right to access all information contained within his own record and to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health information and maintain confidentiality of client records. Rationale 3: The client does have a legal right concerning his medical record, so this option doesn't adequately address the question. Rationale 4: This option is not correct; the client does have a legal right to access his medical records.

The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? Standard Text: Select all that apply. 1. The system is relatively inexpensive to maintain. 2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 4. The system better protects client privacy. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly.

Correct Answer: 2, 3, 5, 6 Rationale 1: This system is not inexpensive to maintain. Rationale 2: This is considered a positive aspect of this type of charting. Rationale 3: This is considered a positive aspect of this type of charting. Rationale 4: The effectiveness of this system to protect a client's privacy is dependent upon the personnel using it. Rationale 5: This is considered a positive aspect of this type of charting. Rationale 6: This is considered a positive aspect of this type of charting.

The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client. 4. Make sure this information gets passed along in the shift report.

Correct Answer: 3 Rationale 1: It is never a good idea to leave blanks in any charting area because it implies that the area was ignored. Rationale 2: It is never a good idea to leave blanks in any charting area. Adding the information in the progress notes is not an appropriate use of that section. Rationale 3: Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank. This would avoid the possible assumption that the assessment or intervention was not done by the nurse. Rationale 4: Passing information along in the report is a good way to ensure continuity of care for clients, but this would only be an oral report, not written documentation.

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? 1. Client fell out of bed, but did push the call button for assistance. 2. Client became tangled in the bed linens, then called for assistance after falling out of bed. 3. Recorder responded to client's call light, upon entering the room, found client on floor. 4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

Correct Answer: 3 Rationale 1: It should never be assumed that the client fell out of bed. Rationale 2: It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else. Rationale 3: Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse learns further information from questioning the client. Rationale 4: It should never be assumed that the client became tangled in bedding, or anything else.

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided, assessment findings, and client problems during a 12-hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording 3. Narrative charting 4. Plan of care

Correct Answer: 3 Rationale 1: Problem-oriented recording is arranging the data according to the problem the client has. Rationale 2: Source-oriented recording is arranged in separate sections for each department that contributes to the client's care. The plan of care is part of the problem-oriented medical record. Rationale 3: Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used. Rationale 4: The plan of care is part of the problem-oriented medical record.

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, in which section should the nurse document this information? 1. Data (D) 2. Action (A) 3. Response (R) 4. Planning (P)

Correct Answer: 3 Rationale 1: The data (D) section reflects the assessment phase of the nursing process, and consists of observations of client status and behaviors, including data from flow sheets. Rationale 2: The action (A) category reflects planning and implementation, and includes immediate and future nursing action. Rationale 3: The response (R) category reflects the evaluation phase of the nursing process, and describes the client's response to any nursing and medical care. Rationale 4: Planning is a subcategory of the action (A) category.

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it's permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. "Confidentiality and privacy laws don't apply to students." 2. "Most students review so many records and charts that they could not possibly remember details from any one of them." 3. "Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence." 4. "As long as the clinical instructor is in the area, accessing client records is part of the education process."

Correct Answer: 3 Rationale 1: This option is not correct; the laws do apply to students. Rationale 2: Although this may or may not be a true statement, it is not an appropriate response to the student's question. Rationale 3: For purposes of education and research, most agencies allow students and graduate health professionals access to client records. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health professional to protect the client's privacy by not using a name or any statements in the notations that would identify the client. Rationale 4: Although this is true, the nursing instructor should not imply that the laws of confidentiality don't apply to students.

The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception

Correct Answer: 4 Rationale 1: Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Rationale 2: Focus charting is organized into data, action, and response sections, referred to as DAR. Rationale 3: SOAP charting is a way to organize data and information in the client's record: S = subjective data; O = objective data; A = assessment; P = plan. Rationale 4: Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE.

After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? 1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an "X" through the entire page, identify it as an "error," initial, and move on to the correct chart. 4. Draw a single line through the documentation, write "mistaken entry" next to the original entry, and initial it.

Correct Answer: 4 Rationale 1: Erasure, blotting out, or correction fluid should not be used. Rationale 2: Erasure, blotting out, or correction fluid should not be used. Rationale 3: When a mistake is recorded, the correction applies to only the erroneous information, not the entire page. Rationale 4: When a mistake is recorded, a line should be drawn through it and the words "mistaken entry" written above or next to the original entry, then initial or signature—whichever is agency policy. The original entry must remain visible.

Before providing care, the nurse reviews the client's pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The client's medical record 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex

Correct Answer: 4 Rationale 1: The medical record contains this type of information, but the complete chart is lengthy and would take the student more time to review. Rationale 2: The MAR includes only those medications that are prescribed or scheduled to be administered during the client's stay. It would not include other information like diagnostic tests, daily care, and so on. Rationale 3: The written care plan may be utilized, but there is another more effective option available. Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. The system is on either an index-type file or a computer-generated form. Information is usually organized into sections: client history/information, list of medications, IV fluids, daily treatments and procedures, diagnostic procedures, allergies, how the client's physical needs are met (type of diet, bathing needs, etc.), and a problem list with stated goals.