Chapter 10 Prep U 251
At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?
2015 Explanation: Military time uses a 24-hour time cycle instead of two 12-hour cycles. So, 8:15 p.m. is equivalent to 2015.
What is the primary purpose of an incident report? Format for audiotaped report Means of identifying risks Basis for staff evaluation Basis for disciplinary action
Means of identifying risks Explanation: An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members nor is it a basis for staff evaluation. The format is usually written and not an audiotaped report.
The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider? eMAR CBE SBAR SOAP
SBAR Explanation: The nurse should use SBAR to communicate verbally to the health care provider. Situation, Background, Assessment, and Recommendation (SBAR) is the communication tool to provide critical client information to the health care provider. eMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.
Which strategy would provide the most effective form of change of shift report? Discussing the client's visitors and complaints during the prior shift. Recording the report for the oncoming shift prior to leaving the unit. Providing the oncoming nurse the client's clipboard prior to leaving the unit. Utilizing a reporting form and allowing time for any questions.
Utilizing a reporting form and allowing time for any questions. Explanation: A change-of-shift report is a discussion between health care team members leaving their shift and health care team members coming on duty for the next shift. It includes a summary of each client's condition and current status of care and should be in a standardized format to ensure concise and accurate information. It is not useful to discuss the client's complaints and visitors during the prior shift. Tape recording and giving the nurse the client's clipboard doesn't allow the oncoming nurse to ask questions.
In SBAR, what does R stand for? Response Report Recommendations Reinforcing data
Recommendations
The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. "I will use only agency-approved abbreviations." "I will write, print, or type information legibly." "I will stay logged in on the computer until the end of my shift." "I will elaborate on the details on my entry in the clients' records." "I will draw a straight line through any blank space."
"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space." Explanation: Writing, printing, or typing information legibly will prevent the entry from losing its value for exchanging information if it is unreadable. Using only agency-approved abbreviations promotes consistency in interpretation. Drawing a straight line through any blank space will reduce the possibilities that someone else will add information to the current documentation. Staying logged in on the computer until the end of the shift is incorrect, as it is a security risk. Best practice is that the nurse logs off each time the nurse has completed an entry. Elaborating on the details on the entry in the clients' records is not in keeping with best practice. The entry should be brief but complete.
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client whose status is stabilized a client who is homebound and needs skilled nursing care a client who is not making progress in expected outcomes of care a client whose rehabilitation potential is not good
a client who is homebound and needs skilled nursing care Explanation: Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.
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 consultation. conferring. reporting. a referral.
a referral. Explanation:Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: interpretation of data. relevant data. factual statement. important information.
interpretation of data. Explanation: A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.
A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality? discussing the medications with a unit nurse providing the instructor with plans for care writing the client's name on the student care plan providing information to the physician about laboratory data
writing the client's name on the student care plan Explanation: Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.
A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response? "HIPAA legislation only allows access to review the medical record." "According to HIPAA, medical records cannot be changed." "HIPAA legislation allows for you to change any information." "According to HIPAA legislation, you have a right to request changes to inaccurate information."
"According to HIPAA legislation, you have a right to request changes to inaccurate information." Explanation: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.
Which data entry follows the recommended guidelines for documenting data? "Following oxygen administration, vital signs returned to baseline." "Client is overwhelmed by the diagnosis of pancreatic cancer." "Client's kidneys are producing sufficient amount of measured urine." "Client complained about the quality of the nursing care provided on previous shift."
"Following oxygen administration, vital signs returned to baseline." Explanation: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today" and "overwhelmed." The nurse should avoid the use of stereotypes or derogatory terms when charting and should chart in a legally prudent manner. If necessary, the nurse should also document subjective statements by the client in quotations.
Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication? "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." "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." "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." "I am calling about Mr. Jones, who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."
"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." Explanation: SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.
Which are examples of breaches of client confidentiality? Select all that apply. A nurse discusses information about a client with a coworker in the elevator. A nurse checks the health record of a client to see who is the contact person for an emergency. A nurse uses a computer to document a client's response to pain medication. A nurse updates the employer of a client regarding the client's date of return to work. A nurse shares his or her computer password with another nurse who was unable to log in to the system.
A nurse discusses information about a client with a coworker in the elevator. A nurse shares his or her computer password with another nurse who was unable to log in to the system. A nurse updates the employer of a client regarding the client's date of return to work. Explanation: Breaches of client confidentiality are a serious problem. These include discussion of a client with a coworker in the elevator, a nurse allowing another nurse to use his or her password to log into the computer, and a nurse updating an employer about when a client can return to work. Nurses may use computers to document client data as long as they are not in a public area and as long as the computer is shut down following the entries. A nurse can also check the health care record for a relative to call in case of an emergency.
The nurse is tasked to organize weekly care plan conferences with other health care team members. Which would be appropriate items to include in this meeting? Select all that apply. A conversation addressing the need for durable medical equipment when the client goes home A review of a client's current progress in the plan of care A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A recommendation for pain management by the emergency department physician who admitted the client a week ago A discussion of the meal plan for a client with diabetes
A report on a client's rehabilitation plan from the physical therapist, including whether changes need to be made A review of a client's current progress in the plan of care A discussion of the meal plan for a client with diabetes A conversation addressing the need for durable medical equipment when the client goes home Explanation: Care plan conferences are discussions about client care, usually involving several disciplines. Interdisciplinary conferences help to coordinate services so that the client's plan of care can be developed and implemented in the most efficient way. Nurses may initiate these conferences and invite members of the health care team from other departments (e.g., physical therapy, social services, dietary). Clients who most benefit from such conferences are those with multiple, complex problems. The emergency physician is no longer needed to address care provided in the health care facility.
Which statement is not true regarding a medication administration record (MAR)? The MAR distinguishes between routine and "as needed" medications. The MAR identifies routine times for medication administration. If the client declines the dose, the nurse does not have to document this on the MAR. After using an electronic MAR, the nurse should log off.
If the client declines the dose, the nurse does not have to document this on the MAR. Explanation: If a client declines a dose, the nurse should circle that dose and write a note as to why the nurse did not administer it. MARs can distinguish between routine and "as needed" medications identify routine times for medication administration. After using an electronic MAR, the nurse should log off to prevent others from inadvertently adding information about other clients to the initial client's record.
The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? Nurse's shift report Telemedicine report Incident report Transfer report
Incident report Explanation: An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.
The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? PIE SOAP SBAR MAR
SBAR
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? narrative charting FOCUS charting PIE charting SOAP charting
SOAP charting Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.
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? The client is coughing and experiencing severe heartburn in the morning. The client has symptoms in the morning associated with a heart attack. The client has a history of severe complaints in the morning. The client reports waking up this morning with a severe headache.
The client reports waking up this morning with a severe headache. Explanation: The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.
The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The provider can input orders remotely into the EHR system for the nurse to retrieve. The nurse can implement care once written orders are received from the provider. The nurse can accept verbal orders to provide immediate care and record once the client is stable. The client must be stabilized before the nurse can obtain any orders from the provider.
The nurse can accept verbal orders to provide immediate care and record once the client is stable. Explanation: In most agencies, the only circumstance in which the attending physician, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the physician/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Physicians/providers can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a flow sheet a medication record a 24-hour fluid balance record acuity charting forms
a flow sheet Explanation: A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.
With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. current orders identifying demographics, including diagnosis any abnormal occurrences with the client during the shift what the client watched on television during the shift what time the nurse will return for the next shift
any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders Explanation: Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next.
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: ensuring that abbreviations are understandable to clients who may seek access to their health records. using only those abbreviations that are defined in full at another location in the client's chart. limiting abbreviations to those approved for use by the institution. using only abbreviations whose meaning is self-evident to an educated health professional.
limiting abbreviations to those approved for use by the institution. Explanation: In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.
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 the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? any family member of the client health care professionals of the facility those directly involved in the client's care close friends of the client
those directly involved in the client's care Explanation: Only those directly involved in client care are entitled to access the client's information. Family members and close friends do not have access to the client's records, as per the privacy policy applicable to each client. Health care professionals of the health care facility may not access client information unless involved in that client's care at that time..